15100159 i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10101 BUBB RD CONTRACT R:SC BUILDERS INC PERMIT NO: 15100159
OWNER'S NAME: CACITTI ROSALIE TRUSTEE&ET AL 910 THOMPS N PL DATE ISSUED: 10/20/2015
OWNER'S PHONE: 9175660765 SUNNYVALE,CA 94085 PHONE NO:(408)328-0688
LICENSED CONTRACTOR'S DECLARATION JOB DESCRI TION: RESIDENTIAL E] COMMERCIAL
License Class- Lic.# APPLE-T.I.PREP(15,600 S.F.)
- �
Contractor c .;, 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.
Sq.Ft Floor Area: Valuation:$16000
I hereby affirm under penalty of perjury one of the following two declarations:
t 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 APN Number: 5720003.00 Occupancy Type:
eIf atice of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this PERmir EXPIRES IF WORK IS NOT STARTED
permit is issued.
APPLICANT CERTIFICATION
WIT 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 180 DAYS FRO L SPECTION.-
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 a by: Date• t) tJ
upon.the above mentioned property for inspection purposes. (We)agree to save
L
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may a e against said City in consequence of the
granting of this permit. io a y e applicant understands and will comply with RE-ROOFS:
all non-point s re la" ns r Cupertino Municipal Code,Section 9.18. All roofs shall bc inspected prior to any roofing material being installed.If a roof is
Signature Date
installed without first obtaining an inspection,I agree to remove all new materials for
( .--!y inspection.
Signature ofApplicant: Date:
OWNER-BUILDER DECLARATION
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. I,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the azardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
2. I,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Se tion 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will
1. I have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance wit"t e Cupertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the Health&SafetyMee_,'A 25505,25533,and 25534.
performance of the work for which this permit is issued. O er or o
. .t
2. have and will maintain Worker's Compensation Insurance,as provided for by —Date: 1 V--Z0
f
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
3. 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If,after making this certificate of exemption,I for which this pet mit is issued(Sec.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name
must forthwith comply with such provisions or this permit shall be deemed Lender's Addre s
revoked,
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my 1 lans shall be used as public records.
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 Licensed Profes 'oval
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
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.
Signature Date
CONSTRUCTION PERMiT APPL CATION
COMMUNITY DEVELOPMENT DEPARTMENT•BU WING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3 55
CUPER (408)777-3228 FAX(408)777-3333•buildin cutertinaor /�j
TthtO — 0/�
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMTT Y
PROJECT ADDRESS/ APN y
OWNER�NAIYM
r( ! s PH _
c rus 1-7 6-66 �1746�S
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STREET DRESS C STATE,ZIP '� �h'� g
CONTACT NA1,4E PHONE _! E-MAIL /
1 C_Tr� At ��' S b C9'
STREET ADDRESS CITY,STATE, 2IP FFA
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❑ OWNER ❑.OWNER-BUILDER ❑ OIA'N--RAGENT ❑ CONTRACTOR ❑CONTRACTOR AG ❑ ARCHITECT ❑ENGINMER ❑ DEVELOPER ❑TENANT
CONrRACTORATAME LICENSENUM -P LICENSETYPE I� BUS.LIC
7
COIviPANY NAME. i
E-MAIL FAX
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od 91
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STREET ADDRESS - CITY STATE,ZIP PHONE
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ARCHITECTJENGIh'EERNAME LICENSE DUMBER BUS.LIC fr
COMPANY NAME EMAIL FAX
STREET ADDRESS L.�0a
CITY,STAT�E,�ZIP 5 PHONE
DESCRIPTION OF WORK
TIE: X0
ARE' 10
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EXISTING USE PROPOSED USE CONSTR TYPE 4 STORIES
SE TYPE I OCC. I SQ.FT. VALUATION{Sj
EXISTG NEW FLOOR DE1,40 TOTAL - _--
AREA AREA AREA 1,IErAREA
BATHROOM KITCHEN OTHER .
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREADECK AREA TOTAL DECKJPORCH AREA GARAGE AREA: DETACH
❑ATTACH
DV;ELLING UNrrS: ISA SECOND UNrr ❑YES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? E]NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF I IS THE BLDG AN El
_ T7 Q®
PLANFI,IINGAPPLm ❑NO PLANNING APPROVAL LETTER EICHL£RHONIE? [] 0
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By my sienature below,I certify to each of th ]lo I am the property oaamer or authorize a_ent to act on the�atjetty ou s behalf. I have read this
application and the information I ha rov' ed's ort have read the Description of Work and verify it is u _ e to comply with all applicable Ioca1
ordinances and state laws relatinto bui . nst c I authorir-eseritatives'of Cupertino to enter ntified property for inspection purposes
Signature of Applicant/Agent: Date:
SUPPLEMENT2t-IATFORMATION REQUIRED
-
NTew SFD or Multifamily dwellings: Apply for demolition permit for
T� OVER THE C07JhTER BIIIIDL�GPL4NS2ES�lES .
existing building s). Demolition permit is required prior to issuance of building
permit for new building. ] ss [� P
`Jti7:.RU`ELA"h,REV-LEWD
r - - �.
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure z�l IMWAxn- W. pusL7c oRxs
form if any Hazardous Materials are being used as part of this project. ¢� _ � � It
�}�W s
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. fl 7QR x i 'rrAR�sI— D�s�Rz
z.s:,,.v-^�_ ��. .,_. g_��:E�aYII20NMElQT;4L.HEAliTFI-�
Bld,-App_201I.doc revised 06/21/11
CITY OF CUPERTI NO
FEE ESTIMATOR-BUILDING DIVISION
Y; ADDRESS: 10101 BUBB RD
DATE: 1 D12012015 REVIEWED BY: MELISSA
APN: 357 20 003 BP#: *VALUATION: $16,000
PERMIT TYPE: Building Permit PLAN CHECK T E Alteration/Addition /Repair
PRIMARY Commercial Building Civil/Religious activities PENTAMATION
inBQzone? Yes (D No PERMIT TYPE: 1TIPREi
WORK APPLE -T.I. PREP 15 600 S.F.
SCOPE
h?,h. 7Jernn'il}'2e: 111i/7nb.lleivn f `'F,q{- I�� —]..................... .: [sLl7rl rT J'ee:
r
CJrri rr h re.,Irzs�. ,
C1,r'2ar l ltstttr .Irt l. Olhel°IElee. hl,".-l.
_-Wc'h. fnsp. Fee: Pfunzh.1nsp. Fee: hhEC'. fr clp, Fee.
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These.fees are based on the preliminar information available and are onlv an estimate. Contact the De t or addn'l in o.
FEE ITEMS L&e Resolution 11-033 Ef.7/U13� FEE QTY/FII-,E MI SC ITEMS
Plan Check Fee: $0.00 01# Tenant Improvement Prep
Suppl.PC Fee: (j) Reg. 0 OT 0,0 1 hrs $0.00 $417 00 1TIPREP
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Feer Reg. 0 OT 0 0hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax: IBCONSTAXC $0.00
Work Without Permit? 0 Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
rawel Docr�r>'rtc�nialion.t=ees:
Building or Structure
Strong Motion Fee: IBSEISMICO $4.48 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SI�BTOTALS $5.48 $417. 0 _. _ TOTAT�=FEZ. $422.48
Revised: 10/01/2015