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15010175CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10931 N DE ANZA BLVD OWNER'S NAME: VIDOVICH JOHN T ET AL OWNER'S PHONE: 4082552166 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # I 1 �{U&s +SM�' Date ' Contractor d I hereby affirm that I am licensed under the provisiol 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. 1 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. 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 permit is issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is correct. l 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 indemnily 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signatu ate ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, wil I do the work, and the structure is not intended or offered for sale (See.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 permit is issued. 1 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date CONTRACTOR: EDWARDS &SONS PERMIT NO: 15010175 AUTOMOTIVE EQUIPMENT 3573 VINEYARD AVE DATE ISSUED: 01 /29/2015 PLEASANTON, CA 94566 PHONE NO: (925) 918 -7449 JOB DESCRIPTION: RESIDENTIAL [] COMMERCIAL GOODYEAR; INSTALL GROUND LIFT Sq. Ft Floor Area: I Valuation: $17000 APN Number: 32610061.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FIZ6AST CALLED INSPECTION. Issued by: Date: �— �1)r RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.I2 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505,25533, and 2554. j Owner or authorized CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(dcupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION 4 ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 1, 7APN# v 82.1p-io-ow OWNERNAME Tavi No th rin ,o 21U, L E -MAIL � FAX CONTACT NAME PHONE E -MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER- BURDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CO L1CL� 1 LICEb?P� all."A • E -MAIL � Awe I W n .Oof 1'1 FAYgS h ©.1///N00.0i�Z 111 IAq4 BUS. LIC # G • LICENSE NUMBER MA1 .312. qUq 11L; E AD ES Y, qy�2 P 5'-2 • /1M DESCRIPTION OF WORK in in *LP. V Y 130 1 EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ATTACH # DWELLING UNITS IS A SECOND UNIT ❑ YES SECOND STORY YES BEING ADDED? ONO ADDITION? ONO PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED B . T=: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO 1 By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I ha4e mad this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws rela ' to building constru ion. authorize re resental#4es of Cupertino to enter the a ove -id ntified prope for inspection purposes. ' Signature of Applicant/Agen Date: SUPPLE AL INFORMATION REQUIRED PLAN CBECK TYPE ROUTING SI>p ❑ OVER- TH&COUNTER ❑ BUILDING PLANREVIrw New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLAWGNG PLAN JMVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11 STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to 11 MAJOR ❑ SANrrARYSEVYERBISTRtC'I' submittal of Building Permit application. ❑ ENVIRONMENTALIIEALTH BldgApp_2011.doc revised 06121111 lw'o CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10931 n de anza blvd FEE ID DATE: 01/29/2015 REVIEWED BY: Mendez UNITS APN: D BP #: , 01- Ste- `VALUATION: $17,000 -PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building USE: $179 PENTAMATION 10EAP 8 PERMIT TYPE: WORK good year; install ground lift SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY /FEE QTY UNITS BP FEES Other Power Devices 1 BREMPOWER 1 # $179 PME Unit Fee: $179.00 PME Permit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC $179.00 Strom Motion Fee: IBSEISMICO 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 based on the nreliminary information available and are only an estimate. Contact the Dent for addn'i info. FEE ITEMS lee Resolution I1 -053 Eff 7%11"13) FEE QTY /FEE Elec. Plan Check 0.0 hrs $0.00 Elec. Permit Fee: IEPERMIT Other Elec. Insp. 0.0 hrs $48.00 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 based on the nreliminary information available and are only an estimate. Contact the Dent for addn'i info. FEE ITEMS lee Resolution I1 -053 Eff 7%11"13) FEE QTY /FEE MISC ITEMS i PME Plan Check: $0.00 PME Unit Fee: $179.00 PME Permit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Travel Documentation Fee: ITRAVDOC $48.00 Strom Motion Fee: IBSEISMICO $4.76 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $325.76 $0.00 TOTAL FEE: $325.76 Revised: 01/06/2015