15040055CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10191 S DE ANZA BLVD
CONTRACTOR:
PERMIT NO: 15040055
N
OWNER'S NAME: HEINE MARYLOU A TRUSTEE & ET AL
DATE ISSUED: 04/08/2015
OWNER'S PHONE: 4157482672
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
STERLING BANK - T.I. PREP OF 2600 S.F. INTERIOR
r_
License Class Lic. # IR 0 � 7An-
DEMO
Contractor G 1L Ir!Yt i 1i�fi Date 8
/,n
/ 7-1 1503001
1 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:
1 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
Sq. Ft Floor Area:
Valuation: $8000
performance of the work for Which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
ection 3700 of the Labor Code, for the performance of the work for which this
APN Number: 35910015.10191
Occupancy Type;
permit is issued.
APP%ICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WIT PERMIT ISSUANCE OR
to building construction, and ereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
AYS F ST CALLED INSPEC ION.
indemnify and keep harmles§1 the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence oft
granting of this permit. Additionally, the applicant understands and will comply
Y ate:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature? Date td
RE- ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
L+�
i
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
❑ OWNER - BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 & Professions Code)
I, as owner of the property, Irn 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. 1 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 1
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner authorized agent: Date:
permit is issued.
or �
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, 1
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
CONSTRUCTION PERMIT APPLICATION O
D
COMMUNITY DEVELOPMENT DEPARTMENT •BUILDING DIVISION /�
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 � V
(408) 777 -3228 • FAX (408) 777 -3333 • buildingacupertino.org \ /
CUPERTINO
❑ NEW CONSTRUCTION ❑ ADDITION E ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PEWMIT #
PROJECT ADDRESS D s
APN # [ / �� O) S- l O
OWNER NAME 5 -n
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CONTACT NAME ,�' !/
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STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER - GUILDER ZOWNER AGENT ❑ CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT 1:1 ENGINEER El DEVELOPER 1:1 TENANT
CONTRACTOR NAME G
Tic ENSE NUMBER 8�o-�A
LICENSE TYPE n
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BUS_ LIC #
COMPANY NAME l
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CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NgME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
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FAX
STREET ADDRESS
CITY, STATE, ZIP
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DESCRIPTION OF WORK 12 F-6 ^ L A 1
e
z,6 0
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
'C
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NE FLOOR
DEMO
TOTAL
AREA n I. O� jl
J•
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: U DETACH
[]ATTACH
# DWELLING UNITS.
IS A SECOND UNIT ❑ YES
SECOND STORY [-]YES
BEING ADDED? ❑NO
ADDITION? []NO
--
PRE- APPLICATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
IVED B - =
AL VALU TION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By my signature below, I certify to each of the following: I am the property owner or authorized et on the property owner's behalf. I have read 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 relating to building construction. authorize representatives of Cupertino to enter the above - identified property for inspection purposes.
Signature of Applicant/Agent: _ 15,4ULV 3 1h%C- Date: Z/o
SUPPLEMENTAL INFORMATION REQUIRED
PLAN cHECx' TYPE'
ROUTING, SLIPj
El �ovER- THE couivTER
anv
❑ BTiHDnvcPixEVJEw
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
-
permitfornewbuilding.
❑'EXPRESS;
❑ PLANNRVC,PLANREVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD,
❑ Poetic woxxs
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
❑ MAroR
❑ SANrrARY SEwERDISTRrCT
submittal of Building Permit application.'
-
❑ ENVIRONMENTAL HEALTH w
BldgApp 2011.doc revised 06121111
I
FM-7, CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
NOTE. This estimlate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc ). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 E ' 7/1 /13)
ADDRESS: 10191 S DE ANZA BLVD
DATE: 04/0812015
REVIEWED BY: MELISSA
APN: 35910015.10191
BP #: a� 5�
`VALUATION: 1$8,000
*PERMIT TYPE:' Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Corlamercial Building
USE :,
.c
PENTAMATION 1TIPREP
PERMIT TYPE:
WORK
STERLING BANK T.I. PREP OF 2600 S.F. INTERIOR DEMO
SCOPE
NOTE. This estimlate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc ). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 E ' 7/1 /13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$417.00
Tenant Improvement Prep
ITIPREP
.c
0,0
NOTE. This estimlate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc ). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 E ' 7/1 /13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$417.00
Tenant Improvement Prep
ITIPREP
Suppl. PC Fee: Q Reg. Q OT
0,0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feejo Reg. Q OT I
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
E)
Strong, Motion Fee: IBSEISMICO
$2.24
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$3.24
$417.00
TOTAL FEE:
$420.24
Revised: 04/01/2015