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14100087{ CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10092 BIANCHI WAY I CONTRACTOR: CRW INDUSTRIES PERMIT NO: 14100087 I OWNER'S NAME: CUPERTINO COMMUNITY HOUSING DI 15346 SCOTTS VALLEY DR STE E I DATE ISSUED: 01/06/2015 1 OWNER'S PHONE: 6503562928 1 SCOTTS VALLEY, CA 95066 1 PHONE NO- (831) 426 -0743 j dff LICENSED CONTRACTOR'S DECLARATION License Class A. —7CIO f,Lic. # �� Z!�D Contractor Date 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. JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] SITE STORM DRAIN REPAIR INCLUDING WALKWAY REPLACEMENT. 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 ywxfet'fi ance of the work for which this permit is issued. Sq. Ft Floor Area: J 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 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 C 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 /✓ ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (See.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. 1 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. 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 become subject to the Workers 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. Date Valuation: $50000 APN Number: 35907019.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAY CALLED INSPECTION. Date: If RE- ROOFS: All roofs shall be inspected prior to any rooting 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 9.12 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 25534. Owner or authorized agent: Date: 4//5 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 Add ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professi CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 CUPERTINO (408) 777 -3228 • FAX (408) 777 -3333 • building(ckupertino.orq ❑ NEW CONSTRUCTION ❑ ADDITION y! ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROTECT .ADDRESS ` o L ! u �G / ( �Q APN #��./j ^ l p (� OWNER NAME jj Lr NE G �d `> ri? E -MAIL p C� P ,a rtt �S� S(�cy .T_i. 4 v-1�ew s�� %1 Ceti° C" STREET ADDRESS r-� .7 V ! J J�C1ll CIT ST TE, ZIP FAX C CONTACT NAME /(�/ Cr PH E) _3 Z g, E- MAILL� P t, STREET ADDRESS / 11 CITY, STATE, ZIP l J, FAX OWNER El OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME � LICENSE NUMBER LICENSE TYPE BUS. LIC # 7 ' COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK , EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEN40 TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA 70TAL DECIOPCRCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNTIS: IS A SECOND UNIT ❑ YES SECOND STORY E] YES BEING ADDED? []NO ADDITION? ❑NO PRE- APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES ; RECEIV BY; - TOTAL VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLERHONIE? NO 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 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 buil ors ctio I authori presentatives of Cupertino to enter the above - identified property for inspection purposes. Signa ture ofApplicant/Agent: 4 - Date; SUPPLEMENTA NFORMATION REQUIRED '"'PLAN CIMCKTWE New SFD or Multifamily dwellings: Apply for demolition permit for ❑ ovER- THECOONTER BUILDING FLANREVIEw existing building(s). Demolition permit is required prior to issuance of building _ permit for new building. ❑l EXPRESS PLANNING PLAI4 REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sTANDAitD PusLlcwoxzxs 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 El' IAaoR, Li sANITARYsEwERDISTRICr submittal of Building Permit application. ❑ - ENVIRONDIENTALHEALTA BldgApp_2011.doc revised 06/21/11 J rm-7, CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10092 Bianchi Way DATE: 10/15/2014 REVIEWED BY: Sean APN: BP #: Q "VALUATION: 1$50,000 }PERMIT TYPE: Building Permit 1 hours Plan Check, Hourly $143.00 ISTPLNCK PLAN CHECK TYPE: Alteration / Repair PRIMARY Multi - Family Dwelling USE: hrs Buildina is 3 Stories 0 Yes Q No PENTAMATION 1GENRES PERMIT TYPE: WORK Site improvements including storm drain repair. SCOPE $0.00 Suppl. Insp. Fee:) Reg. Q OT O,Q hrs 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 preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Eee Resolution 11 -053 Ef ' 7/1 /13) FEE QTY /FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes (F) No $0.00 1 hours Plan Check, Hourly $143.00 ISTPLNCK Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ® Yes (D No $0.00 Suppl. Insp. Fee:) Reg. Q OT O,Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 T_T_ 0 (D Work Without Permit? ® Yes E) No $0.00 Advanced Planning Fee: $0.00 hours Inspections $143.00 ISTINSP Inspection, Hourly G 0 Strom Motion Fee: IBSEISMICR $6.50 Select an Administrative Item Bld&, Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $8.50 $286.00 TOTAL FEE.T $294.50 Revised: 07/10/2014 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 I-'ax: 408-777-3333 JOB ADDRESS: OWN ER'S N A M L,: I't" fZ M IT _67 PHONE _4___ GFNERAL CONTRACI'OR: BI-JSINESS LICE' SE4 ADDRESS: q114 -5�c,?t CVTY�'ZIPCODE: *Our municipal code requires A businesses working in the city to have a Cify of Cupertino busillies's license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) NVILI. BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SLIBCON'I'RACTORS HAN,"E OBTAINED A CITY' OF CIJPER'FINO BUSINESS LICENSE. I am not using any subcontractors: - ------ Signature Date Please check applicable subcontractors and complete the following information: 1;TSUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # ---------- --- Cabinets & Millwork Cement Finishing Electrical Excavation Fencing 2 3525 Flooring Carpeting I Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing ----- ----- - Septic Tanlc Sheet Metal Sheet Rocl< ------ — ----- ------ - Tile Owner itractor Signature ate