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CITY OF CUPERTINO
BUILDING DIVISION ERMW �� 1 TOR if�� i�IrJ Nt
BUILDING ADDRESS: PERMIT NO.
20619 SHELLY DR TBD — TO BE DETERMINED 08010049
OWNER'S NAME: PERAM ISSUE DATE
HO JEAN C AND GILBERT D 02/26/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHiTEC(ENGINEER: BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD 490 SQ(2 BDRM, 1 BTH) &RPLC 1 WNDW W/SLDNG DOOR
6
in full force and effect
License Gas f% Lic.# E3 0/ o /
F m
Date Contractor_ �r3RTs7 r3ClttJ/i!/Hicn
ARCHITECTS DECLARATION
C< 1 understand my plans shall be used as public records
'WU
y Licensed Professional
a OWNER-BUILDER DECLARATION
-t
)<� 1 hereby affirm that I am exempt from the Contractor's License Law for the
G 0 following mason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a permit to construct.alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $80000 Valuation
l- (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or 8 0 0 0 0
.. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number QCCU
not more than five hundred dollars(s500). 359 11021 )V umOccupancy Type
❑I,as owner of the property,or my employers with wages as their sole compensation,
will do the worst,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employers,provided that such improvements are not intended or offered for sale If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li.
cense Law dors not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Polity number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars($100)
or less)
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 m become subject to the Workers'Compensation
Laws of Cali folnia Dalc
Applicant—
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) -
RWi Q Lender's Name
:D Z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
Gr, r-' correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorise representatives of this city to cater upon the
a above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
H rn liabilities,judgments,costs and expenses which may in any way accrue against said City
V z in consequence of the granting of this permit.
t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER�FCyULpTION/Ate—
/ 6 Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as dcfincd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scmion 25532(a)?
❑Yes �No
All roofs shall be inspected prior to any roofing material being installed.
Yes
If a roof is installed without first obtaining n inspection,I
Will the applicant or future building occupant use equipment or devices which g aagree to remove P
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
13 yes flu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,15533 and 25534.1 understand that if the building
docs not currently have a mans,that it is my responsibility to notify the occupant of the
requirements It must be met prior to issuance of a Certificate Occup ry. _
Signature of Applicant Date
Owner or authorized aged
All roof coverings to be Class"B"or better
Date' �
c�
CITY OF CUPERTINO
i ADDITION/REMODEL
CUPER INO PERMIT APPLICATION FORM
APN# r — O� t O) O Date: 1 o �40
��� � I 1
Building Address:
2 ��� S&4-Z ea1PK;R71109, (14
Mailing Address (if different from building address):
Owner's Name: Phone# : HUN f/CAI
-r
U470-E-1)IN Za ori IV -.271-1 .2
14'-
Contractor: Phone#:
Fax#:
Contractor License#:
Cupertino Business License#:
Contact: .� Phone#: -27/ — 2
Fax#:
Building Permit Info:
/
� y
Bldg. Elect. Lam' Plumb. 0 Mech. R", Hillside ❑
Job Description:
Addition(adding sq footage):
aT)I T 1 o 1V OF a S' 2- bd ro a m
What is being remodeled?
.. r
Remodel Includes Re-Roof Yes ❑ No If yes list number of squares
Remodel Includes Structural: Yes ❑ No
Square Footage:
Addition: O Porch: _Deck: Garage: Detached Attached
Remodel: Kitchen Bath Other
Type of Construction (Usage Class): Occupancy Types:
1 FR, 11FR ❑ 11, 111, V-lHR ❑ 11, 111, 1V V-N I�
Valuation: ko Please check this box if the project is a
second-story addition ❑
Green Building Check list must be completed and
Green Building Points Achieved:
attached to the plans. �S
***For Office Use Only***
Over-the-Counter ❑
IS
CITY OF CUPERTINO
ADDITION/REMODEL
CITY OF
CUPE1k1:1N0 FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
ADDITIONS 1F3SFDADD
Ll U PLLONGRNGR Long Range PL
Planning/Residential
1R31NSP . Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1R3REPPLNC Dwellings Repeat Plan B
Check
1R3HINSP Dwellings Hillside B
inspection
1R3HPLNCK Dwellings Hillside B 1
plan check
1R3HREINSP Dwellings Hillside B
Repeat Inspection
1R3HREPLNC Dwellings Hillside B
Repeat.Plan Check
1R3ALTINSP Dwellings Alternate B
Materials Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check
1PCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
jDisposal System
1PRSEWER Sewers P
1BPSPR.INK Lawn P
Sprinkler/Backflow
1BPWSVCS Main Water Service P
1BSEISMICRE SeismicResidential B
DECKS 1R3SFDADD OR
1K3SFDF' +M
1DECKWOOD Deck(Wood)-Each B
(Each) �
1DECKRAIL Deck Railing-Each B
(Each)
• Community Development
. 10300 Torre Avenue
y, ' T Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEQN0
Building Department
JOB ADDRESS: PERMIT #
0&// � SLG 194 -
OWNER'S NAME: TbP/✓ No, f/ov✓#D e#,z/✓ efil' HONE # /S-.2 7/- 2 /
GENERAL CONTRACTOR: f FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date