13060131I CITY OF CUPERTINO BUILDING PERMIT I
IBUILDING ADDRESS: 22826 SAN JUAN RD I CONTRACTORS INC SYTHE GENERAL I PERMIT NO: 13060131
OWNER'S NAME: COSTA PAUL AND PAMELA TRUSTEE & ET I 3108B FILLMORE ST I DATE ISSUED: 09/06/2013
I OWNER'S PHONE: 4084253680 1 SAN FRANCISCO, CA 94123 1 PHONE NO: (415) 440-9191
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #—&1AJCA1
ContractorfO*wAK-rU* rgn4. sor,nt�ate q . (� . (,75
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.
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 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 n n -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date a (0
❑ 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)
I, 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.
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 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.
Date
JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
VACANT LOT -HILLSIDE- CONSTRUCT 2 STORY SFDWL-
1ST
FLOOR 2,524 SQ FT, 2ND FLOOR 131 SQ FT WITH
ATTACHED GARAGE 506 SQ FT
Sq. Ft Floor Area: I Valuation: $500000
APN Number: 34221028.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DA F OM LA T CALLED INSPECTION.
Issued by: Q Date: ��•
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 9.12 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 25.505, 25533, and 25534.
Owner or authorized agent: tAfiy r., f p( bAM, J Date:0l' 4
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 Address
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 ou
(408) 777-3228 • FAX (408) 777-3333 • building(ftwertino.ora
5ZT.MW 1-nWCTRI Tr'TTr)V n AnnTTInN n ALTFRATTON / TT n REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESSAPN
vPe �hoGA 9501
#
3+z -2t -ozo
OWNER NAME pa� fav I Gosfia
PHONE
77C'esZsbo
STREET ADDRESS
IL WOfPi
5�✓
Sv,vlv,; 7
F
CONTACT NAME Lo' lSU`PV✓cit,)l s M4N
PHONE 4-15 O 64- 79 13
�AX
E-MAIL
1
STREET ADDRESS
�
CITY, STATE, ZIP
2wz 1 ('D "' -*I I r'
Ef15-9&,(--761-t,
❑ OWNER ❑ OWNERBUILDER❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT x ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �{ A IA
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER Z '^ 3
�!/n
BUS. LIC #tr
COMPANY NAME r� .
E-MAIL
/�Z 1 r j
(� (/ J /
�j 7
- 0] 0 ' - / D 13
STREET ADDRESSQ
Sr.
CITY, STATE, ZIP
PHONE 4 15 g /_7X_ - �D 13 z
HJT
Zl Vt3�'
J
DESCRIPTION OF WORK
eW 2' Stov (- hDm2 ,)o
Si* m,
EXISTING USE
t
PROPOSEDUSE
P—
CONSTR TYPE
�g
1 # STORIES
2
USE
I YPF:
OCC
SQ P"I'
VALUATION ($)
Vo can L�
St �{anl-1 3
EXISTG
NEW FL66R
DEMO i
TOTAL
AREA O
AREA
AREA
NET AREA I
BATHROOM
10TCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GE AREA: DETACH
FGAR
I 5 O� ATTACH
# DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES
'®NO
' BEING ADDED? ADDITION? JRNO
PRE -APPLICATION 13 YES IF YES, PROVIDE COPY OF
IS THE BLDG AN 13 YES
RECEIVE Y:
'f(,LpL,VATiiATTnN;
PLANNING APPL # ❑ NOPLIIV � PRO AL LETTER
EICHLER HOME? '5 NO
OO D D O
By my Signature below, I certify to each of the following: I am the property owner or authorized ent 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 10traction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: C✓a al G -11G Date:?c %' 14' �3
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ H-,DMG PLAN REVIEW
_ 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
❑ NING PLAN REVIEW
Bldgs: Provide a completed Hazardous Materials Disclosure
ANDA"
PUBLIC WORKS
—Commercial
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
❑
submittal of Building Permit application.
MAJORARY
SEWER DISTRICT
11 ENVIRONMENTAL HEALTH
CITY OF CUPERTINO
FEW FEE ESTIMATOR - BUILDING DIVISION
imlADDRESS:
TYPE OF
CONSTR.
DATE: 06/14/2013
REVIEWED BY:
PC FEE ID
APN: a2 f�a(p 17 G
#: ��D/
*VALUATION: 1$500,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: New Construction
PRIMARY SFD or Duplex
' 2nd Unit? ' Yes • No
PENTAMATION 1 R3HILl
USE:
$0.00
PERMIT TYPE: A
WORK
VACANT LOT- CONSTRUCT 2 STORY SFDWL- 1ST FLOOR 2,524 SQ FT 2ND FLOOR 131 SQ FT
SCOPE
WITH ATTACHED GARAGE 506 SQ FT
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Hillside, Custom)
II-B,111-B,IV,V-B
3,161
$5,013.38
1R3HPLNCK
$3,106.03
IR3HINSP
$0.00
PME Plan Check:
$0.00
Permit Fee:
$3,106.03
Suppl. Insp. Fee:Q Reg. 0 OT
0,0
hrs
$0.00
PME Unit Fee:.
$0.00
PME Permit Fee:
$0.00
TOTALS:
3,161
$5,013.38
Construction Tax: IBCONSTAXR
$3,106.03
# new
units
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
WvtricL etc )_ These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$5,013.38
Select a Misc Bldg/Structure
or Element of a Building
1
Suppl. PC Fee: Q Reg. Q OT
L1'�
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
WvtricL etc )_ These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$5,013.38
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$3,106.03
Suppl. Insp. Fee:Q Reg. 0 OT
0,0
hrs
$0.00
PME Unit Fee:.
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXR
1
# new
units
$641.96
AellniiiistI"alNe? I ec.
G
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee. IPLLONGR
$410.93
Select a Non -Residential
Building or Structure
E)
i
Trm,el Documentation Fees':
Strong Motion Fee: IBSEISMICR
$50.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$20.00
SUBTOTALS:
$9,242.30
$0.00
TOTAL FEE:
$9,242.30
Revised: 04/29/2013
1W
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22826 SAN JUAN RD
CONTRACTOR: FORSYTHE GENERAL.
PERMIT NO: 13060131
CONTRACTORSINC
OWNER'S NAME: COSTA PAUL AND PAMELA TRUSTEE & ET
3108B FILLMORE ST
DATE ISSUED: 09/06/2013
OWNER'S PHONE: 4084253680
SAN FRANCISCO, CA 94123
PHONE NO: (415) 440-9191
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑
VACANT LOT -HILLSIDE- CONSTRUCT 2 STORY SFDWL-
License Class_ Lic. # 3,A541
1sT FLOOR 2,524 SQ FT, 2ND FLOOR 131 SQ FT
r i
6
WITH ATTACHED GARAGE 506 SQ FT
Contractor �e
lX
REVISION #1- REVISE FOUNDATION WALL HEIGHTS,
I hereby affirm that'I am licensed under the provisions of Chapter 9
FOOTING TO COMPENSATE FOR INCREASED
(commencing with Section 7000) of Division 3 of the Business & Professions
EXCAVATION - ISSUED 2/26/14
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: $500000
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: 34221028.00
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. I 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 F ST CA D 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
Iss a e. Z
granting of this permit. Additionally, the applicant understands and will comply
y:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
�t2
RE -ROOFS:
If is
Signature Date V
All roofs shall be inspected prior to any roofing material being installed. a roof
installed without first obtaining an inspection, I 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)
1, 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(a) 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 9.12 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
yrjC/'
Owner or authorized agent: Date:_
permit is issued._S
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
CONSTRUCTION LENDING AGENCY
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
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
1 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
COMMUNITY DEVELOPMENT DEPARTMENT + BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildinciftuoertino.org
❑ NEW CONSTRUCTION ❑ ADDITION
❑ ALTERATION / TI X REVISION /DEFERRED ORMINAL PERMIT # 1 30 Q ( J
PROJECT ADDRESS g V .?V)
AM 11 ` 21 02
OWNERNAME ^ }�
PHONE
EMAR
STREET ADDRESS
CITY, STATE, ZIP C V h 1 / a / FAX
CONTACT NAME . GJ •G'vI
r r�V
PHONE cF'Z a
'�
�
✓
I
STREET ADDRESSC
ZIP
FAX
0
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT *% ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME • _ _ % �. _ 1
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHTTECUENGINEER N
LICENSE NUMBER�''+n & .
(• jalL
BUS. LIC #
COMP NAM!{ I
E-MAII.� + 1
C Q / %� 7
FAX ).%
rr �i
V "V 1� I TiC/' + bye
V/l�`� /o1
STREET ADDREV
CITY, STATE, ZIP
PHONE
/
DESCRIPTION OF WORK
TlY-7`/'J
�/�l i ( (II /
t�1GVp� eiyCG�/y ; ✓ytl
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE TYPE
OCC.
SQ.FT. VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NETAREA
BATHROOM
REMODEL AREA
KITCHEN
REMODEL AREA
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECKIPORCH AREA
GARAGE AREA: 0 DETACH
❑ ATTACH
I
# DWELLING UNITS:
M A SECOND UNrr ❑ YES
SECOND STORY ❑ YES
BEING ADDED? ONO
ADDITION? ONO
,.
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY- VAyiJ ON:
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 agentko a n the property owner's behalf. I have read this
application and the information I have provided is correct. I have re cription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil ' ns o I au ri sentatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENT ORIVATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
El OVER-THE-COUNTER
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
BUILDING PLAN REVIEW
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
El STANDARD
El 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
_
submittal of Building Permit application.
1:1 MAJOR
❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp_201 Ldoc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 22826 SAN JUAN RD
ial
DATE: 02/26/2014
REVIEWED BY: COUNTER
APN:
BP#: 13060131
"VALUATION: I$0
*PERMIT TYPE:Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
hrs
PENTAMATION 1 GENRE
PERMIT TYPE: j]
WORK
REVISION #1 REVISE FOUNDATION WALL HEIGHTS FOOTING TO COMPENSATE FOR
SCOPE
INCREASED EXCAVATION.
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These Pees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef' T-1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes 0 No
$0.00
® hours Plan Check, Hourly
$556.00 1STPLNCK
Suppl. PC Fee: (F) Reg. Q OT0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
O
0
Work Without Permit? 0 Yes '0 No
$0.00
Advanced Planning Fee.
$0.00
Select a Non -Residential 0
Building or Structure O
i
Strong Motion Fee:
$0.00
Select an Administrative Item
Blde Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$556.00
TOTAL FEE:
$556.00
Revised: 01/15/2014
UTILITY RELEASE REQUEST FORM
COMMUNITY DEVELOPMENT DEPARTMPNT - BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
CUPERTINO 10300 TORRE AVENUE - CUPERTINO, CA 95014-3265
(408) 777-3228 - FAX (408) 777-3333 - building0cuperting,org
101
For residential single family or duplex construction, there are cases where gas and electric utilities are
requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the
building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of
the building.
INSTRUCTIONS
1. Download this form at: hLtp./i,wNvw.cupertitio.ter, Lindc\.asl)x?paye
,fz7-
2. Complete the form and obtain signatures from both the owner of the property and the primary contractor.
3. Fax, E -Mail, Mail or hand deliver the original signed form to:
City of Cupertino
Building Division
Attn: Utility Release Request Form 408-777-3228 office
10300 Torre, Ave. 408-777-3333 fax
Cupertino, CA 95014 buildir a(&c
4. Schedule a Gas Meter Release inspection (4403) and/or Electric Meter Release inspection (#404). Please
note, a Gas Test inspection (4506) is required prior to or at the same time of the Gas Meter Release
inspection.
BUILDING INFORMATION (Please complete the following information):
APN
BLDG PERMIT* 0DATE:
'7)2- 1 j5
SITE
-ADDRESS:
OWNER'S NAME'
DIU a J_A_
PHONE #:
FAX 5 3)
MAILING ADDRESS (if different from site address):
CONTRACTOR:
PHONEM
FAX #-. 97 2JSU)-
CONTACT:
-LA w a n 4j)
PHONE*
FAx #:4 Lj
I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of
the building cannot move into the residence until they receive all of the required final sign -oft and the City has issued a certificate of
-occupancy for building.
-Owner ......... ...............................Print:..... ..... ...... ............. Date:.
.......Print: .... PaW.A.e.Blaam.................................... Date:.
UtilityReleaseForm_201 1. doc revised 08109111
Apr.29.2015 01:26 PM Forsythe General Contract 4154409199
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
PAGE. 1/ 1
Building Departw nt
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS:,21r./_6 /I/ PERMIT# /300131
OWNER'S NA 1K 0s PHONE
GENERAL CONTRACTOR: �/, N T. BUSINESS LICENSE #
ADDRESS: - 13 CITY/ZIPCODE: 110 9 y/
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) 'WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
-/?, t4d- 7, �- I /zIV)5
Own / ontraetorSignature ��Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
C' �/S
Electrical
C LAUSEN
l q l
Excavation
9-V 51,10H
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass {61 ing
61-,4SS Cop—P,
L
+1eatftq VAC
Ca KFFo P -T FN t5Iz�Y
Insulation
C ENrP-?1� L CA I N C L4L A T o /V , ( N C•
s�
Landscaping
Lathing
Masonry
Painting spa}-er--.
SC H I Nim A N PA 1 rV 7 1 n/ 6,
Paving
Plastering
F l-AST r 1'—I N
Plumbing
s«
5
Roofing
Lit W S o N R 0 0-f i w G
Tank
c t 5 CO
-Skvmetal
-VT?0 P D l- 1 S M fkL W D p—iz
Sheet Rock
Tile
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Own / ontraetorSignature ��Date
*----------------------------• MetroScan / Santa Clara (CA) ----------------*
Owner :Costa Paul & Pamela Trustee Parcel :342 21 028
Site -:Jacinto Rd Cupertino 95014 Xfered :09/09/2010
Mai :1413 S Wolfe Rd Sunnyvale Ca 94087 Price :$200,000 Full
Use :69 Vacant,Urban Phone
Be rm: Bath: TotRm: YB:1900 Pool:No B1dgSF: Ac:.34
Information compiled from various sources. CoreLogic makes no representations
or warranties as to the accuracy or completeness of information contained in this report.
Susan Winslow
To: luigi@craigsteely.com
Subject: FW: New Address Letter
Attachments: SAN JUAN RD -FORMERLY SAN JACINTO.pdf
Importance: High
Hi Luigi,
am forwarding this new street name/new addr letter to you. Please make sure all plans, and correspondence have the
new address 22826 San Juan Rei on them. Let me know if you have any questions.
Sue
17!--,,: Susan Winslow
S" Thursday, June 27, 2013 10:49 AM
T, I , :1'
-s Letter
L•. . ,a. . '!ic�i�
Hi .'gym,
P ' ' ped the new ar!dress assignment letter that went out yesterday 6/27/13 to all the agencies. I have
C! ! 'street on your permit #13060131 that is in plan review. Please make sure all pages of the plans
i Gals, any correspondence and special inspection/Testing documents show the new address 22826
5 - n let me know if you have any questions.
S. - r„Iy,
c
4 -7:7-324
1
Susan Winslow
To: Paul & Pam Costa
Subject: New Address Letter
Attachments: SAN JUAN RD -FORMERLY SAN JACINTO.pdf
Importance: High
Hi Pam,
Attached is a copy of the new address assignment letter that went out yesterday 6/27/13 to all the agencies. I have
changed the address/street on your permit #13060131 that is in plan review. Please make sure all pages of the plans
including re -submittals, any correspondence and special inspection/Testing documents show the new address 22826
San Juan Rd. Please let me know if you have any questions.
Sincerely,
Susan Winslow
Administrative Clerk
Cupertino Bldg Dept
408-777-3246
City of Cupertino,
I have reviewed the development plans for APN 342-21-028 and am agreeable to the
improvements in the right-of-way. The retaining wall is considered temporary in nature
and acceptance does not constitute a waiver of right of way or future development.
Owners of APN 342-21-027
'tf / d k3
Dat
r
,. -r
.. -� t
/��' �.�-
FREMONT UNION HIGH SCHOOL DISTRICT
589 WEST FREMONT AVENUE
SUNNYVALE, CALIFORNIA 94087
408-522-2200
Developer Impact Fee Compliance
Building permits will not be issued without a completed Certificate of Compliance
Building Permit Application
The City of has received a request for a Building Permit described as follows:
New Residential Development _ Residential Addition (501) sq. ft. or more _ Commercial Development
F
Name of n / Developer: c:2�
Project Address:? Z 2 6 Lot/Parcel # 2 - 1 - 07—�
Square Footage: 2-6-5-5-- Description: U Pe7440� s7k. u T 0('J
Permit / Plan Check # / 0 U / 3
Date: '07 9 T By:
Square footage verified by the city prior
g_ I nspector
to issuance of a building permit; fees may be adjusted accordingly.
Feeder Elementary District 0u`)*V-)
..........................................................................................................................
SCHOOL DISTRICT DEVELOPER IMPACT FEE
CERTIFICATE OF COMPLIANCE
The authorized representative of the Fremont Union High School District has reviewed the
City of
Building Permit Request described above and hereby certifies that the developer or authorized representative has
met the requirements of the District's Developer Impact Fee requirements.
Dated:
Certificate not valid without
District Seal, Initial, and Date
Distribution: Facilities Planning —White City — Yellow
By:
Fremont Union High School District
Authorized Representative
Fee
Requestor — Pink Accounting — Gold
Dev. Impact Fee Compliance (Rev. 11/22/05) [12/08 — 10001
Cupertino Union School District
10301 Vista Drive, Cupertino, CA 95014
Tel (408) 252-3000 • Fax (408) 865-0326
Developer Impact Fee Compliance
The Cupertino Union School District has adopted Resolution Nos. 1403 and 1404, imposing
developer impact fee pursuant to Government Code 53080.
Building Permit Request
The City of has received a request for a Building Permit described as follows:
Residential Development Project ❑ Commercial/Industrial Development Project
Name of Developer:
Project Address: 2 2 Z �an . f �i r ► i / � P U✓ 1�'O "? 4- UC -/70n rj /I
Description: C� o�?7i1 lo -14 / V e,�,v11
l
Square Footage: 6 Lot/Parcel #: '42 Zi 0 Z8 Permit #:
Date: ` :% i By. -- -
City.�luthorized Representative------
Square footage will be verified by the city prior to issuance of a building permit; fees may be adjusted accordingly.
Important Notice:
Cupertino Union School District gives no credit for total demolition of existing square footage area, which makes
way for new construction as mandated in the Government Code Sections 53080, 53080.6 and 65995.
SCHOOL DISTRICT DEVELOPER IMPACT FEE
CERTIFICATE OF COMPLIANCE
The authorized representative of the Cupertino Union School District has reviewed the
City Of r
Building Permit Request described above and hereby certifies that the developer or authorized representative has
met the requirements of the District's Developer Impact Fee requirements.
Dated: By:
Authorized Representative
Cupertino Union School District
Fee: $
Certificate not valid without Check No.:
District seal, initial, and date.
Facilities Planning - White City - Yellow Requestor - Pink Accounting - Gold