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O a_ CIL Dto T cr- Q i1 U U u c a ILM - a� ,� CITE'OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR IN��RMAT�ON BUIL I.G DRESS: PERMIT NO. ��1 RODRIGUES AVE CUPERTINO KITCHEN DESIGNS 08090152 OWNER'S NAME: PERMIT ISSUE DATE PHILIP & AMY BLOCHER 10562 S DE ANZA BLVD 09/23/2008 PHONE: (408) 257-4900 SANITARY NO. CONTROL NO. ARCHTTECT/ENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH 0 0 0 0 O p LICENSED CONTRACTOR'S DECLARATION ui hereby affirm that i am licensed under provisions of Chapter 9(commencing Job Description Z m with Section 70(10)of Division 3 of the Business and Professions Code,and my license is KTC HN RMDL (14 4 S Q) , MINR STRUCTRL; r a a in full force and effect 90L !V 3 j Z License Class13 Lic.li '1 V ELCTRC/PLMB/MECH—NO ROOF 1F,n Date Cif'z'�//� Contractor ARCHITECTS DECLARATION 7 z< 1 understand my plans shall be used as public records .1 >yU a N Licensed Professional y OWNER-BUILDER DECLARATION } I hereby affirm that 1 am exempt from the Contractors License Law for the 00 following reason.(Section 7031.5,Business and Pmfcssions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement ?a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor ea Valuation F (commencing with Section 70(X1)of Division 3 of the Business and Professions Code)or 60000 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type not more than five hundred dollars(3500). 3 6904043 Q2 ❑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 and Professions Code:The Contractors License Law dors 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.). ❑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 docs 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 Contractors License Law. C]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: ❑I ha+c and will maintain a Certificate of Consent to self-insure for Workces Compen- sation,as provided for by Section 3700 of the tabor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Carier.S�4Aa- 6,,,t1"Ai.- V;>SPolicy No.:/11120410f 20 0� CERTIFICATEOF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for onehundred dollars($100) a or less.) I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensadon Laws of Califomia.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the worker's Compensation provisions of the Ichor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z— CONSTRUCTION LENDING AGENCY F~-+LOO I hereby affirm that them is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) ALender's Name , Lenders Address U Q I unify that 1 have read this application and state that the above information is IL"-" correct.I agree to comply with all city and county ordinances and state laws relating to 0U building construction,and hereby authorize representatives of this city to enter upon the U ahove-mentioned properly for inspection purposes. ' (We)agree to save,indemnify and keep harmless the City of Cupertino against tiliabilities,judgments,costs and expenses which may in anyway accrue against said City U Z in consequence or the granting of this permit. i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURC REGULA'I�OJS..�---�� Re-roofs Signature of Applicant/Co etor Date �--- - HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes �lo Will the applicant or forum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes E2 Nu I have read the hazardous materials requirements under Chapter 6.95 of the Califor. nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the re uirem ts which theme met ter to i�tt cc of a C-crtifi&or Occupancy. Signature of Applicant Date q ��nt �p e All roof coverings to be Class'}``or better Owner or authorized agent Date 0�dq o 1562" CITY OF CUPERTINO e, ADDITION/REMODEL CUPEkTiNO PERMIT APPLICATION FORM APN# 30 ®,/ 6), / ` ® � Date: Building Address: J5 0 1 V �� ce�1N0 6A 96ol Mailing Address (if different from building address): Owner's Name: yip Phone # s� A11 ; A, All © 1 1 6 — -3 -zS4 Contractor: Phone#: ZS' `7— K q o (./ Cu er4Ind kC4-G6,r-, _Ze5 � n Fax #: z5,7 —&Y-SY Contractor License#: & 0 0 4163 Cupertino Business License#: r H 7d tq Contact: Phone#: 7-7 7- / 7S Z K /G GeFax zS 7-,041 3y Building Permit Info: Bldg. 2/ Elect. Ef Plumb. [Y Mech. [/ Hillside ❑ Job Description: Addition (adding sq footage): What is being rem_fodeled (not including addition)? K� TG�/E� ,�' C/ JTr✓ Com" V rdY l/ 2 � � f I�Q �� I✓l ,�/!y An p� yltLcAGi. qc Remodel Includes Re-Roof: Yes ❑ No [ If yes list number)of squares Remodel Includes Structural: Yes ❑ ' No ❑ Do you have the pre-application planning approval? Yes ❑ No [� If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/IIIN-A ❑ II/III B, IV-HT, V-B 5Z 3 U Valuation: .11-1 Please check this box if the project is a second-story addition ❑ Project Size: Express ❑ Standard ❑ Large ❑ Major❑ Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, Green Building Points Achieved: include in plan set& the sheet index. ***For Office Use Only*** Over-the-Counter ❑ Revised 7/15/08 CITY OF CUPERTINO E ADDITION/REMODEL CUPEr OF FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft ADDITIONS 1R3SFDADD PLLONGRNGR Long Range PL Planning/Residential 1R3INSP Dwellings Inspections B - 1 R3PLNCK Dwellings plan check B 1 R3REPINSP Dwellings Repeat B Inspection 1R3REPPI.NC Dwellings Repeat Plan B Check 1R3HINSP Dwellings Hillside B inspection 1 R3HPLNCK Dwellings Hillside plan B check 1 R3HREINSP. Dwellings Hillside B Repeat Inspection 1R3HREP.LNC Dwellings Hillside B Repeat Plan Check 1R3ALTINSP Dwellings Alternate B Materials Inspection 1R3ALTPLNC Dwellings Alternate 'B Materials Plan Check 1 PCESS Cesspool P 1PPRSEWG Ea. Private Sewage P Disposal System 1 PRSEWER Sewers P 1BPSPRDIK Lawn Sprinkler/Backflow P 1BPWSVCS Main Water Service P 1BSEISMICRE SeismicResidential B DECKS 1R3SFDADD OR 1R3SFDREM 1 DECKWOOD Deck (Wood)-Each B (Each) 1DECKRAIL Deck Railing-Each B (Each)