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14090020CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10260 JOHNSON AVE CONTRACTOR: CRAIG A ROGERS PERMIT NO: 14090020 CONSTRUCTION INC OWNER'S NAME: SAHA BRATIN & MULLICK ATRAVEE 3914 WELLINGTON SQ DATE ISSUED: 12/04/2014 OWNER'S PHONE: 4085824661 SAN JOSE, CA 95136 PHONE NO: (408) 499-3354 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ 8-1 �0 3 CONSTRUCT NEW TWO STORY RESIDENCE (2190 SQ FT); License Class Lie. ftq7s BASEMENT (371 SQ FT); ATTACHED GARAGE (449 SQ FT); Contracto . ., Date I 1 PORCH (99 SQ FT). I hereby affirm that I am licen ed under the provisions of ClIpter 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 Sq. Ft Floor Area: Valuation: $530000 of the work for which this permit is issued. rrformance I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 37525060.00 Occupancy Type: permit is issued. j APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is 4F WORK IS NOT STARTED PE7DAROM correct. I agree to comply with all city and county ordinances and state laws relating WOF 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 18AST CALLED INSP CTION. 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 Issued byDate: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. V RE -ROOFS: Si.. ## j a (/7`� Date j� ! All roofs shall be inspected prior to any roofing material being installed. If a roof is 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 1, 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, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the of the work for which this the Health & Safety Code, Seeins 25505, 25533 nd 25534. � r �" performance Via: Or ret izant�lifi'razeritz�eti '"�' Date:�y e permit is issued. 61/ 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 Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construct n 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 ec 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 [I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10260 JOHNSON AVE CONTRACTOR: CRAIG A ROGERS PERMIT NO: 14090020 CONSTRUCTION INC OWNER'S NAME: SAHA BRATIN & MULLICK ATRAVEE 3914 WELLINGTON SQ DATE ISSUED: 12/04/2014 OWNER'S PHONE: 4085824661 SAN JOSE, CA 95136 PHONE NO: (408) 499-3354 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] License Class Lic. # '=� CONSTRUCT NEW TWO STORY RESIDENCE (2190 SQ FT); BASEMENT (371 SQ FT); ATTACHED GARAGE (449 SQ FT); < _ _PORCH Contractor �A� A • ' 7 to j�Date 15 (99 SQ FT). rev # 1- add 240 s.L to covered porch area - issued 2/3/15 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 Sq. Ft Floor Area: Valuation: $530000 erfor nance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 37525060.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 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 D -FROM LAST CALLED INSPE TI N 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 I Date: with all non -point source regu tions per the rno Municipal Code, Sectio 9.18, RE- OFS. Signature Date All roofs shal spected p or to in material being installed. If a roof is installed without first obtain' 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) I, 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 i 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, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 2553 , ar d 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, I shall Owner or authorized agent: Date: not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 IlAtNloj (408) 777-3228 • FAX (408) 777-3333 • building(a1cupertinO.orct ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI 4!9 REVISION / DEFERRED ORIGINAL PERMIT # l ` V C VU W PROJECT ADDRESS 0 / v � PL JG Q� N, APN # ca r! �/ /y� D OWNERNAME bW,I1A(sjollpA, ���/i�/ 1144//! 1 VCITY, PHONE (fo P+%�jc��-446 E-MAIL STREET ADDRESS STATE, ZIP FAX CONTACT NAME l,IL'�vdl, PHONE t y3i) E-MAIL �j� 6,9d- C, STREET ADDRESS /,01 ��/Yj ��`�aH � CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME C�AI� LICENSE NUMBER S -s j LICENSE TYPE BUS. LIC # COMPANY NAME +Ll ccnij A, LZ,r �. f.4 E-MAIL :.J ar( f O F L (95 - -7161 STREET ADDRESS f I (( S0 c W 11 CITY, STATE, ZIP S`, PHONE ARCHITECT/ENGINEER NAME(L`iJ(6 LICENSE NUMBER BUS. LIC # 6 / a,,� [ti COMPANY NAME 160 0 : / E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTIONOF WORK /� ACj EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: EIDETACH ❑ ATTACH # DWELLING UNITS; IS A SE ND UNIT ❑ YES SECOND STORY ❑ YES BEING DED? E] NO ADDITION? ❑NO PRE -APPLICATION []YES IF YES, OVIDE COPY OF IS THE BLDG AN ❑ Y -RECEIVED BY;' TOTAL VALUATION: PLANNING APPL # ❑ NO P APPROVAL LETTER EICHLER HOME? By my signature below, I certify to eac of the following: I am the property owner or auth nze roperty owner's behalf. I have read this application and the information I have pr vide orrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil in cons ction. I authorize representatives of Cupertino to enter the above -identified prope for inspection purposes. Signature of Applicant/Agent: Date: 3 SUPPLEMENTAL INFO ,MATION REQUIRED '` PLniv ciECK TYPE ROUTING SLIP ❑ OVER=rHE-COUNTEx Q BDn DItvGPt nN REVIEW . New SFD or Multifamily dwellings: pply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑' EXPRESS ❑ "PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑° 'sT aNDnRD ❑ PUBI IC woRics = form if any Hazardous Materials are being used as part of this project. []LARGE, ❑, > e MIT' Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAaoR ❑ sEwER ' submittal of Building Permit application. snNrrARY nisTlucT "^ ❑ ENVIRONMENTAL HEALTH . ' BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO F,M-,7- FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 10260 johnson ave DATE: 02103/2015 REVIEWED BY: melissa APN: 375 25 060 BP#: '`VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: 1 0.0 1 PENTAMATION 1 GENRES PERMIT TYPE: WORK rev # 1 - add 240 s.f. to covered porch area - issued 2/3/15 SCOPE NOTE: This estimate does not include fees due to other Departments fi.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, eta). These fees are based on the preliminary information available and are only an estimate. Contact the Dept_for addn'l info. FEE ITEMS (Fee Resolution-] 1-053 F, . 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q) No $0.00 1 hours $143.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: (E) Reg. 0 OT 1 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? Cl Yes Q No $0.00 Suppl. Insp. Fee:Q Reg. Q OT 10--01hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 %-'onsfruction 1;2,1.: ,ldininistr(ftity Fee: 0 E) Work Without Permit? 0 Yes (2) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 i Tl,avel Docu.:raentcaffori.Fee,s: Strong Motion Fee: $0.00 2.0 hrs $286.00 Inspections ISTINSP Inspection, Hourly Bldg Stds Commission Fee: $0.00 SUBTOTALS ° $0.00 $429.00 h TOTAL FEE ' $429.00 Revised: 01/0612015 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 EUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building aacuoertino.org I /`I.1\EW CONSTRUCTION n ADDITION n ALTERATIOINT / TI n REVISION /DEFERRED ORIGINAL PER-Wr n PROJECT ADDRESS 102,60 APN `3 7:[ 9:5 � �1 r rp O�TERNP.I4E �RAi,11J �}H� Pi3�I E yag Sgt W 91 I E-1✓,AIL 4JiGl�lYlrS�hcl`� iYi6cfL'� STREET ADDRESSC / CITY, STATE, ZIP (1 A I / FAX .4 O� I L 6-b CONTACT NAME �I/►� IJP PHO"'T [ADO --1 1 1 ^ �y E-MAIL 11 i& MEj> 6 ® Ot>"L' STREET ADDRESS V i') g 0 . o m e_sl� �P fl/ ri1 1'7 (,`❑ CITY, STATE,, ZIP /l _. n ,� (� O 9 /;'/i 150TH`1 FAX ❑ OWNER ❑ OWNER--BBUILDEK ❑ OWNER AGENT CO�VNMZAI CTOR ❑ COKPRSCT`0„R('A(GENTI�ARCHI'!RCTCT ❑ EN&I2N _R ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 7•'LICENSE NUMBER LICENSE TYPE •/ , VV BUS. LTC 9 COMPANYNAE 11 E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE f ARCHITECT)ENGINTEER NAME Nary � /d /�'7 �CENSE NUMBER BUS. LIC COMPANY NAME E-MAIL VAN AA�N5(§) P �'% _ FAX STREET ADDRESS e+ry //)6P9 JH®�v p�n `/ %%41 V 7 (• �J GG��//YY//��-- r1 ��/11. LCITY, STATE, ZIP � D'/ � 11b, ' N J PHONE !y%L�- 7 7t, -5q �I ��+ / r DESCRIPTION of WORK AA AV EX1kTINGL`SE I PROPOSED USE CONSTR_n1PE +STORIES USE TYPE I OCC. SQ.FT. VALUATION (S) EXISTG AREA 15,00 NEW FLOOR AREA :g1 q0 TOTAL DEMO TOTAL AREA / r OU NET AREA V &I BATHROOM REMODEL AREA �/ KITCIv-FN REMODEL AREA OTHER REMODEL AREA PORCH ARFA DECK AREATOTAL DECI:IPCH AR'r..A GARAGEAREA El D-inA� m DWELLING U!,7TS: IS A SECOND UNIT❑ Yfr6' SECONDSTTORY YES 1 BEING ADDED? 0 ADDITION? ❑NO -PR£-rIPPL-iC-AEON-{-]-1'65-7r��S,-P-R01�IDE-COPTOF �STHE BLDG AN rl )ES BY ---�' ,_,,. `y.v; T AL V6.LUATION: PLANNIINGAPPL: nN'O PLANZ. T0APPROVAL LETTER EICHLERHOME? E]NO - By my signature below, I certify to each of the following: I am the property owner or au I d agent to act on th rope er's behalf. I have rad this application and the information I ) ave provided is correct. I have read the Description of Wo r and v it is ac agree to comply Mth all applicable local peerty for inspection purposes. ordinances and state laws relating'to building construcc/tiio IF, hort a representatives of Cu ertin o ter the above/-iidenti e7/4 Signature of Applicant/Agent: Y/ Date: _ "I SUPPLEMENT AL INFOR 4ATION REQUIRED Q �.,_a x ROUT733G SIP New SFD or Ivlultifamil y d%:vellings: Apply for demolition permit for P ? t ©o«xcounTEx BTJILbL1GPI A'� RE�Ii 1T L s.. existing building(s). Demofit On permit is required prior to issuance of buildings; for building. MOO . permit new ....REss �1 A7<r;I�G�t TiRRztE Commercial Bldgs: Provi e a completed Hazardous Materials Disclosure �STAARD { ��uBLicWORxs _ z � foim if any Hazardous Maferial are being used as part ofthis project. LARGE '_. uy _ Copy of Planning Approval etter or Meetintr With Planning prior to Building Permit I.❑-It'Li7©�2vv `'-`� ? `� �a- x uu R7.k �iT�S EFLDIST.F •�SA,Al2I`�Ci'..ICTc'��•�,: submittal of appl�eation. �� s� "T. ti r g.�}��� r y r y •mss' .,-�', Bldg4pp_2011.doc revised 06/21/11 6w I,5 CITY OF CUPERTINO IJ/�I FEE ESTIMATOR— BUILDING DIVISION OCCUPANCY TYPE: 10260 Johnson AVe DATE: 09/04/2014 REVIEWED BY: Sean JimADDRESS: APN: BP#: "VALUATION: 1$530,000 *PERMIT TYPE: . Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex USE: 2nd Unit? 0 Yes •' No PENTAMATION 1 R3SFDW PERMIT TYPE: A WORK Construct new two story residence 2190 sq ft • attached garage 449 sq ftporch 99 sq ft). SCOPE $0.00 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 2,738 $3,025.83 1R3PLNCK $2,916.89 1RMNSP $0.00 PME Plan Check: $0.00 Permit Fee: $2,916.89 Suppl. Insp. Fee -.0 Reg. C) OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 2,7383 a Construction Tax: IBCONSTAXR $2,916.89 unit $667.63 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 hated on the nrelinduary information available and are only an estimate. Contact the Dent for addn'1 into. FEE ITEMS (Fee Resolution 11-053 E . 711113) iblcc•h. Plan Checic Plumb. Plan Check F.lec. Phan Check kfech..PermitFee: Plumb. Permit Fee: flee;. Per?nit Fee: Otlre, Xlech. Insp. L Other Plumb Insp, Other Flee. Insp. Li :Ltech, Imp. Fee: Plumb. Insp. Fee: Elec. Insp. 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 hated on the nrelinduary information available and are only an estimate. Contact the Dent for addn'1 into. FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $3,025.83 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $2,916.89 Suppl. Insp. Fee -.0 Reg. C) OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXR 1 unit $667.63 Athninislrative Fee: 0 Work Without Permit? 0 Yes (F) No $0.00 Advanced Pl.annin Fee: IPLLONGR $383.32 Select a Non -Residential Building or Structure 0 i Travel Documentation Fees: Strong Motion Fee: IBSEISAHCR $68.90 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $22.00 SUBTOTALS:' $7,084.57 $0.00 " :TOTAL FEE:"° $7,084.57 Revised: 08/2012014 g - e argent �j City Of Cupertino 10300 Torre Avenue �( Cupertino., CA 95014-3255 Telephone: 408-777-3228 CUPERTINO�� /_ Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: 7& PERMIT # OWNER'S NAME: 6, TV- 1 _ 3 PHONE # - _419 GENERAL CONTRACTOR: BUSINESS LICENSE ADDRESS:�U CITY/ZIPCODE: 5 *Our municipal code requir alI bush sses working in the city to have a City of Cupertino business license. NO BUILDING FINAL_ OR FINAL- OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE, GENERAL CONTRACTOR_ AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY -OF, CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please cbeck applicable subcontractors and completethefollowing information: SUBCONTRACTOR"- - BUSINESS -NAME BUSINESS LICENSE 1 f Cabinets & Millwork ice-. %� ► f� , ��� Cement Finishing Electrical ri [�� � 5 Excavation �� -. LI Fencing m Flooring /Carpeting Clk ; Linoleum -1 Wood -� td't A r�if] rCjhCV_K 17 =. Glass / Glazing - 191 . : Heating Imo_ k l Insulation �. Landscaping Lathing_k4 Masonry. ura Painting / Wallpaper 4 (@ P Paving Plastering .� 0yV Plumbing eea chi Roofing Septic Tank Sheet Metal i R. . Sheet Rock QS i� q Tile cJ lt�~ C61tractor Signature Date CUPERTINO PURPOSE UTILITY RELEASE REQUEST FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building @cupertino.org For residential single family or duplex construction, there are cases where gas and electric utilities are requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of the building. INSTRUCTIONS 1. Download this form at: httR://www.cupertino.org/index.aspx?page=297. 2. Complete the form and obtain signatures from both the owner of the property and the primary contractor. 3. Fax, E -Mail, Mail or hand deliver the original signed form to: City of Cupertino Building Division Attn: Utility Release Request Form 408-777-3228 office 10300 Torre Ave. 408-777-3333 fax Cupertino, CA 95014 building2cupertino.org 4. Schedule a Gas Meter Release inspection (#403) and/or Electric Meter Release inspection (#404). Please note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release inspection. BUILDING INFORMATION (Please complete the following information): APN 7 c)(0o777 MIT #: 1 io /��c) 0 Z oDATE: "� 1_1�_ 4 SITE ADDRESS: O NER'S NAME -PHONE T Z -N �I 6 L,. #: /103 FAX #: `7 MAILING ADDRESS (if different from site address): C TRAM OR: FAX#E#.q� C) CONTACT: � � F� #E # I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of the building cannot move into the residence until they receive all of the required final sign -offs and the City has issued a certificate of occupancy for the building. Owner: ...........: f� {.. .. L ..... .' ............. Date:...... . .............................. Print:..i gip. �'�.. . I ... �n!.........�.....(`.i./.�/........ ....... �.......... Contractor:.... t.J.. �.... ...lc'n1.aru..............................Print:!1�(j....... ......C�.C1...�`.��.........I...Date:.J.a.` 6.-) ...... UtilityReleaseForm 2011.doc revised 08/09/11