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15110177so im CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10195 WESTERN DR CONTRACTOR: JEMICO LLC DBA PERMIT NO: 15110177 RENEWAL BY ANDERSEN OWNER'S NAME: TILLMAN JESSE L AND MARION C 30800 SANTANA ST DATE ISSUED: 11/24/2015 OWNER'S PHONE: 4082578137 HAYWARD, CA 94544 PHONE NO: (510) 263-3178 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL F] REPLACE 1 (E) FRECH DOOR WITH (N) IN KITCHEN License CIV Lice r -7 (SAME -� SIZE & LOCATION) Contracto,� Date�"I I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the erformance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $10151 have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35911005.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS F_RC ALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. II ) LDated 1 ROOFS: being installed. If is SignatLJ any r a roof All roofs shall be inspected prior to y roofing material installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(x) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, thapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Section 5505, 55 3, and 25534. II r Section 3700 of the Labor Code, for the performance of the work for which this 5�r'r�� I Owner or authorized agent: Dat• i permit is issued. 10, I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save , ARCHITECT'S DECLARATION indemnify;and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature , Date CONSTRUCTION PERMIT APPLICATION COMMiiUNI I Y DEVELOPIVENT DEPAR i IViENT - BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildino(c—DcuDeriino.orQ CUPERTINO [ ❑ NEW CONSTRUCT ION ❑ ADDITION ❑ ALT -ERATION / iT ❑ REVISION / DEFFERICED OZIGi�iaL PF-Izm i FPRo��cr ADDREss4b �� Q�l'�� +a I hPN R / 00 Oti?�=RNA1J (moi 'F 1 `I1 v'- \ I P30]v� H 6-%— s77 ET ADDR --- ss ), b -i q GJ- W nik.m b r I C11 Y, STAT R, ZIP I FAX CON ACT NA ` ^ ,^ C' ` �_ Ck- I PH" S N.4II MGWl 111e�C�lU� I( STREE-1 ADDRESS ✓v�lio C1� i/L.yIQ L�f CITY, STATE, ZIP 1�„ ( I%i /, IS -1 1 J� FA-- ❑ 01;N -.R ❑. OWh-RAGMNT tCCONIRACrOR ❑ CON.TR C:TORAGTT ❑ ARCTII-CT ❑ =T1GL>\ R ❑ ❑ T-_)\f,h-r CONiRACTORTAi✓ LIGTSB2.U1J3r'R � LiCDNSc TYPE � Ctf�I BUS. LIC f �"J� CO1J,pA1vYNA.ha �Ll�`;�� V� `^ � I N4IL I Y l✓�' 1'.1{I /�L��WV�'�lJ-�Cll LS*11 U�� ST^n ET ADDRESS CI -AY, STAin, ZIP r � J�/'j � (� P? ON- ARC:—TIi ECTrNGL -'EF-RNA]✓,E LICENSE Nlj. SE BUS. LIC m COMPA4TyNRJJ.E B-21CU?L I FAX STREET ADDR SS I GiY, STAia, ZIP I Pti01 DESCR21 T70NT OP WORK =SslG UcE PROP,OA L'S CONS -4-R, TYPE '' S TORTE'S SI✓� USE I TYPE I OCC. SQ.FT. VA-UATION(S) ` -TG A'EW FLOOR DEI`/,0 TOTAL hR=A APIA f R -A NET AREA I BA T 11ROOM FTCT OT R REMODREA EL A --MODEL AREA ?040DEL AREA PORCHAREA D=CKAR=A TOTALDEClKiTORCiARMA G.=.RAGEP.R2A: Lj DETACH ❑ ATTACH nDWRLLII.G NTPS: IS A SECOND UNIT El YES SECOND STORY ❑1=S I BEING ADDED? ❑N:0 ADDITION? ❑N,0 PP :UPT ICATNON ❑ 1 FS IF 1'=S, PROVT= COPY OF IS THE BLDG AN a = TOT.1L�V? LLj.4T10N: PLfN'NIN'G APPL R ❑ NO PLAI\R.TsG APPROVAL L=TI=R FICKLER HO ? ' El -- v By my signature below, I certify to each of the follo;;'ing: I am the properj' o;; r authori?A _ nt on the prope,-ty ov let's behalf. I hzve ;end this -=application-and-the-information-I-have provided-.is_correct:---I-have-read-the-Description ofZ� r. a veri y ;t=is accurate:= I ae ee to�omply;;itlz zll applicabN.e ICk0- ---"- ordinances and state la;vs re]ating to build g coast, tion, I authorize representativeS'of Cupertino to enter the abov!e�io'e 1*Med perry for inspection pu poses, _Signature of Applicant/Agent:. - ... -A' .1_ _ -. _.. _� �G�"_..___._ ___ __ _ Date---.�7o-'JT�-FJ-ti.----- .__--- --•------_--..--- -.-- SL-PP..El`1_2\T-�A L _ r0IZ1`4.ATIOIN REQUIRED New SFD or Milhifa_mily du elli Vis: apply for demolition pt=it *or t �� « � eYlStiri� building(s). De Ti011t10Ii pei Ilt IS .e0U1Pd crier t0 iSSlla ce Of build,_- g 04�R SCOL�TrR — �� - BLTr1DL�GPL3 Ti Rs;7i x pecrit for new buildin o1g. _ Co:ninarcial Bldgs: Provide a completed Hazardous Materials Disclosure T4�eRn L� C o for -in ifany H2ZZzd011S A/faterizls- e being used as part efthis project __ I IcSARG) Copy of Plan ?ing Approval L, --Ler or ?��eetirg wit l Plal l r� prior to _ ubm:ttal of BL:ldin� PenTlit application. Su o TvLOR r�fi ��TfaYeST iit.DIcTRiCT� ,ri Y, on sE�.r�a`L��;..�:x:. B1dp,`�jp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION Tech. ficin Check ()thei' 110ch. IiispJ ktsh. I'I.W. lila-: 'L>hv nb. 111 an €`he ek ()fher J)h!nib l srr. I'l11 Yi17..hi p. Fee: lace. Alan Check Elec. 1'erivit Fee: o `ier 1:r`'ec'. Insp. 7 r. NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Ltstrtct, etc.). i hese Tees are oasea on the preliminary information avattante ana are onty an estimate. contact the wept for aaan't to/o. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13, ADDRESS: 10195 WESTERN DR DATE: 11/24/2015 REVIEWED BY: MELISSA APN: 35911005 BP#: *VALUATION: 1$10,151 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: Suppl. PC Fee: (a Reg. () OT PENTAMATION 1GENRES I PERMIT TYPE: WORK REPLACE 1 E FRECH DOOR WITH N IN KITCHEN SAME SIZE & LOCATION SCOPE Tech. ficin Check ()thei' 110ch. IiispJ ktsh. I'I.W. lila-: 'L>hv nb. 111 an €`he ek ()fher J)h!nib l srr. I'l11 Yi17..hi p. Fee: lace. Alan Check Elec. 1'erivit Fee: o `ier 1:r`'ec'. Insp. 7 r. NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Ltstrtct, etc.). i hese Tees are oasea on the preliminary information avattante ana are onty an estimate. contact the wept for aaan't to/o. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13, FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # $431.00 Window / Sliding Glass Door 1 WINREP I Replacement Suppl. PC Fee: (a Reg. () OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. O OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C.;t3JisZruclion 11x: .zI di'ninZ:Sfralive /'lee: 0 '% Work Without Permit? O Yes • No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 tY n el .�. o6.u�i7t'.Yllfi ion Fees: Strong Motion Fee:: IBSEISMICR $1.32 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 T SUBTOTALS : $2.32 $431.00 TOTAL,FEE $433.32 Revised: 10/01/2015