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CITY OF CUPERTINO
BUILDING DIVISION PERMIT C� TRACTCrlR IC �tMATIQN
PERMIT NO.
BUII,p1,1;ICygp[]RT_ PLETREE PL TIMBERLINE HOME SERVICES, 08020162
OWNER'S NAME: TNC PERMIT ISSUE DATE
LARRY CHAMPAGNONI & ABBIE 27724 MEDLAR DR 03/21/2008
PHOW irmn>\T SANITARY NO. CONTROL NO.
(510) 258-6066
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u 0 p LICENSED CONTRACTOR'S DECLARATION
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z U, with Section 7000)of Di''on 3 of the Business and Professions dg.,and my license is RMDL—1 NEW WNDOW, ATTIC ACCESS STAIRCASE
in full force and elf- 7
j Z Licen C s Lic.q
F,p Date Contractor /
ARCHITECTS DECLA ATION
oC< 1 understand my plans shall be used as public records
D a U
Low Licensed Professional ,
OW NER-BUILDER DECLARATION
<� I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m Pu which requires a permit to construct,alter,improve,demolish,or repair any structure
y rn 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 Valuation
= g ) ) $2000
(commencing with Section 7000 of Division 3 of the Business and Professions Code)or
y .. 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 �,�.]�j Number Occupancy Type
not more than five hundred dollars(E500). 3 2 3 4 4 0 3 1 .`(7Y?'
❑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
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 employees,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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does 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.
❑1 am exempt under Sec ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sarion,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 Worker's Compensadon 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 Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(5100)
or less.) ,,//
1 certify that in tite mfmance�ffikfor which this pe it is issued.1 shall not
employ any perso i ` anne ome sub'6et to t W rkers'Compensation
Laws of Calif , a
Applicant /
NOTICE TO NT: f,after making this ertifi ate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 O forthwith comply with such provisions or this permit shall be deemed revoked.
Z V) CONSTRUCTION LENDING AGENCY
��
[--i r--r 1 hereby affirm that there is s construction lending agency for the performance of
FY.> the work for which this permit is issued(Sec.3097,Civ.C.)
O.t A Lenders Name
=z Lenders Address
V 0 1 certify that 1 have read this application and state that the above information is
(y— correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives or this city to enter upon the
W above-mentioned property for inspection purposes
E„ CL (Wo)agree to save,indemnify and keep harmless the City of Cupertino against
(/� liabilities,judgments, nd ez uses which may in any way accrue against said City
V Z �APPLI
con
c f the g ng � is permit.
'— onsNDE AN SAND WILL COMPLY WITH ALL NON- Olrrr Issued by: DateOUR A NS., p%
1 Re-roofs
Sign✓ o ppll, on for Date
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will the applicant rn future building occupant store or handle hazardous material
as defined by the Cupertino Mun'oipa!Code.Chapter 9.12,and the Health and Safety
Code.Section z5532(a)?
❑Yes NAll roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future riding occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District? _
❑Yes Nu
1 have read the hazardous in tq nials rEquirements under Chapter 6.95 of the Califor-
niaHcalth&SafetyCode,SectionsM5,7S533and25534.1understandthati dtcbuilding
does not cuts a tenant,that itis my responsibility to notify the upant f the
requirements m be m prior to issuance of a Certificate of a anry. Signature of Applicant Date
2 � All roof coverings to be Classor better
Owner or afidi rix d agent Date
CITY OF CUPERTINO
ADDITION/REMODEL
CUPEK rINO PERMIT APPLICATION FORM
APN# / L/D / , 0 0 Date: 17
Building Address:
Mailing Address (if different from buil ing address):
Owner's Name: Phone#
r� /II — Cc5 u , 0 7
Contractor: Phone#:
rv�e_e-s ,zwG Fax #:
Contractor License#: OXY S-_2
Cupertino Business License#: 0976
Contact: Phone#:
Fax #: 5_/0 - 61- 11,7.3/
Building Permit Info: 5'r—D y2,2r„,.6c)LQ_A
Bldg. W Elect. ❑ Plumb. ❑ Mech. ❑ Hillside ❑
Job Description:
Addition(adding sq footage):
What is being remodeled?
Remodel Includes Re-Roof: Yes ❑ ' No Fv'] If yes list number of squares
Remodel Includes Structural: Yes 2' No ❑
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath Othe
Type of Construction (Usage Class): Occupancy Type:
1 FR, 11F ❑ 11, 111, VAHR ❑ 11, 111, 1V V-N
Valuation: _ 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. eveZ
***For Office Use Only***
Over-the-Counter ❑
CITY OF CU]PERTINO
ADDITION/REMODEL
CUPS ANO FEE SCHEDULE
Quantity Fee ID , Fee Description Fee Group .Permit Type
Sq Ft
ADDITIONS 1R3SFDADD
PLLONGRNGR Long Range PL
Planning/Residential
lR31NSP Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPITJSP Dwellings Repeat B
Inspection
1R3REPPLNC Dwellings Repeat Plan B
Check
1R3HINSP Dwellings Hillside B
inspection
1R3HPLNCK Dwellings Hillside planB
check
1R3HRElNSP Dwellings Hillside B
Repeat Inspection
1R3HREPLNC Dwellings Hillside B
Repeat Plan Check
1R3ALTINSP Dwellings Alternate B
Materials Inspection
lR3ALTPLNC Dwellings Alternate B
Materials Plan Check
1PCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
Disposal System
1PRSEWER Sewers P
1BPSPRINK Lawn Sprinkler/Backflow P
1BPWSVCS Main Water Service P
1BSEISM[CRE SeismicResidential B
DECKS 1R3SFDADD OR
1R3SFDREM
1DECKWOOD Deck(Wood)-Each B
(Each)
1DECKRAIL Deck Railing-Each B
(Each)
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
CUPEkTINO
Building Department
JOB ADDRESS: �3 PERMIT #
OWNER'S NAME: =� a� Sr' 1 t PHONE # �/C-
GENERAL CONTRACTOR: FAX #
0�
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