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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22460 STARLING CT CONTRACTOR:HILL CONSTRUCTION PERMIT NO: 10040161
CO
OWNER'S NAME: JONATHAN G BORNSTEIN&PHYLLIS BROCK 1775 COASTLAND AVE DATE ISSUED:06/11/2010
OWNER'S PHONE: 408406267I SAN JOSE,CA 95125 PHONE NO:(408)440-2831
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL(]
License:Class (� Lic.# 5�1 KITCHEN REMODEL,ADDING LIGHTS/OUTLETS DINING
rr'' /^ &FAM
Contractor R+o C. sk. 6 • Date 10-1k' k O RM(110SQ);NO RE-ROOF&HAS STRUCTURAL
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$25000
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:32613025.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I 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 DAYS FROM LAST CALLED INSPECTION.
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 byyi.----` Date:
with all non-point source
�regulations per the Cupertino Municipal Code,Section
9.18. I✓jw[n' W
/_d`` �� RE-ROOFS:
Signature Date v 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
1 hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant:_ Date:
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)
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
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.I2 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section s 25 05,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this g J_
permit is issued. _ J
Owner or authorized agent: Dater
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 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
CITY OF CUPERTINO
14
a ADDITION/REMODEL
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
32 �o C3 - 02S 4/2-7110
Is a 2" unit being added? Yes ❑ No ❑ If yes, please fill out the permit application for 2" unit.
Building Address:
2 2 i(o p CCC�c�
Mailing Address (if different from building address):
Owner's Name: Phone
s _ korf t 4®k62 (oI
Contractor: Phone# 7,031
QCT_1 Fax #:
Contractor License#: W&�(q 1
Cupertino Business License#:
Contact: Phone#:
Fax #: Qj gj — t �
Building Permit Info:
Bldg. [V Elect. ['� Plumb. IRI Mech. I+ / Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including addition)?
�` CA � !� r� LtcA�is i UETS `PIr�ih6 t
Remodel Includes Re-Roof: Yes ❑ No If yes list number o squares FkM 1 L Ll '1
Remodel Includes Structural: Yes [p- 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 �I V Bath Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ 11/III 3
B, IV-HT, V-B --
Valuation: $...2, 000 Please check this box if the project is a
second-story addition ❑
Project Size: Express 7standard ❑ 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 07/06/09
al,
CITY OF CUPERTINO
ADDI'T'ION/REMODEL
CUPEI�IFINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee.Group Permit Type
Sq Ft
ADDITIONS 1R3SFDADD
1PLLONGRNGR Long Range PL
Planning/Residential
1 R3INSP Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1 R3REPPLNC Dwellings Repeat Plan B
Check
1 R3HINSP Dwellings Hillside B _
inspection
1R3HPLNCK Dwellings Hillside plan B
check
1 R3HREINSP Dwellings Hillside B
Repeat Inspection
1 R3HREPLNC Dwellings Hillside B
Repeat Plan Check
1 R3ALTINSP Dwellings Alternate B
Materials Inspection
1 R3ALTPLNC Dwellings Alternate B
Materials Plan Check
1PCESS Cesspool P
1 PPRSEWG Ea. Private Sewage P
Disposal System
1 PRSEWER Sewers P
1BPSPRINK Lawn Sprinkler/Backflow P
1BPWSVCS Main Water Service P
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE SeismicResidential B
1RER00FRES Residential Re-roof Each B
100 SF