13070009 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1115 ROLLINGDELL CT CONTRACTOR:ENGINEERED SOIL PERMIT NO: 13070009
REPAIRS,INC
OWNER'S NAME: VUCENIC WAYNE AND KUBIAK VALRI 1267 SPRINGBROOK RD DATE ISSUED:08/06/2013
OWNER'S PHONE: 4084460268 WALNUT CREEK,CA 94597 PHONE NO:(925)210-2150
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALE]
License Class N L Lic.# CD(o t('9 9 FOUNDATION SUPPORT&UPGRADE.REMOVE(E)
3 WOOD
Contractor Date �' POSTS&REPLACE WITH ADJUSTABLE METAL SCREW
II hereby affirm that I at licensed under the provisions of Chapter 9 JACKS.
(commencing with Section 7000)of Division 3 of the Business&Professions INSTALL SUBDRAIN ALONG REAR&LEFT SIDE
Code and that my license is in full force and effect. PERIMETER
I hereby affirm under penalty of perjury one of the following two declarations:
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
IVI Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35934008.00 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 0 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter j
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA SF OM LAST CALLED IN SPE ION.
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 by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date �' 6' `3 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
I 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
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
II 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 2553
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Dater
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 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
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255 O
CUPEATC140 (408)777-3228- FAX(408)777-3333> building aacupertino.org
❑NEW CONSTRUCUON ❑P ADDITIN ElALTERATION/TT ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 1115- RO I!I d o l t Ccvr�• APN k 35c? - .3 (-`f - LoO
OWNER NAME N N1JUC.GEMkC- PHONE _ YG. 026 E-
MAM4
STREET ADDRESS I � �. Cv STAT C� 9sa/Y FAX
CONTACT NAMETi77 E-MAIL
SERV/O
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STREET ADDRESS CITY, ATE,ZIP FAX
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❑ OWNER ❑ OWTTER-BUILDER ❑ OWNER AGENT Er_co�ACTOR ❑CONTRACTOR AGENT ❑ ARC=CT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE BE LICENSE TYPE BUS.LIC#
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COMPANY NAME E-MAIL FAX
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ARCHITECT/ENGINEERNAME LICENSE NLA4BER BUS.LIC k
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COMPANY NAME E-MAIL FAX
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STREET ADDRESS 0 CITY, TAT ZIP PHONE
n q„-$d� b 6% (i►VI- CrJee L5-210
DESCRIPTION OF WORK
FIFvOve, E W00 0 POs T-1 A pts P at- f5°t-A f-C Ot-Jrf-910 tZ LMS I RFPLA<'1
0 ui R Lr M l'6'1'� S�12� J �n !a lOgrvu�Lt pot r t /-
EXISTING UPSE PROPOSED USE CONSTR TYPE R STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA MIODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH
k DR'ELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEINGADDED? []NO ADDITION? []NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF LS THE BLDG AN ❑�YES i= �-;. ,.� ;� � .-ar= TOTAL V 4LUATION:
PLANNING APPL X ❑NO PLANNING APPROVAL LEITER EICHLER HOME? ❑ O «* f.�
y ,:. # Z S G rid
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on t pro 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 acc e. I agree to comply with all applicable local
ordinances and state laws relating to buildin ction. I au ize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Asent: Date: -7- Z - 13
SUPPLEMENTAL INTFO MATION REQUIRED ¢'` F•rt j
�.�.
New SFD or Multifamily dwellings: Apply for demolition permit for
flPOVER THE-COUtrTER 4 "s `❑�BUILDJI�G PLANREVTEW '�
existing building(s). Demolition permit is required prior to issuance of building _ ,
permit for new building. I� E7.PxEss �� Y � ~R � *j
❑S PLAI�"NIIvGPLA_NF�EVLEWv
� fl �1�0„,
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sraiDARDF n' 314 pvBLICV~O RI.s ,' "ti
form if any Hazardous Materials are being used as part of this project. fes . ”
'"�3
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ SA1rTTARY SE�]�R DTSTRICT T.
submittal of Building Permit application.
1•., _ [� ,,.r 1..�.r.,f� -.❑- ENVJRONh�\TAL`HEAI,TIt�
31d,-App_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 1115 ROLLINGDELL CT DATE: 07/02/2013 REVIEWED BY: MELISSA
APN: 359 34 008 BP#: 3 ) 0 2 *VALUATION: 1$25,000
*]PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
FWo
RD FOUNDATION SUPPORT& UPGRADE. REMOVE E WOOD POSTS & REPLACE WITH
SCOPE ADJUSTABLE METAL SCREW JACKS. INSTALL SUBDRAIN ALONG REAR & LEFT SIDE p
Ma.-h. Plan Check Plrunb, Plan Check Lice.Plan Check
At<clr. Pcrmil fee, Plumb,permit Fee: Elec. Permit Fee:
Other Afech.Insp. Other PhInab Insp. Lj —I_ Ocher 1,lec.Insp.
ET--[-
11cch.Insp. Fee; Plumb, Insp, Fee: Elec.Insp.Fee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (Fee Resolution 11-053 Elf' 7/1112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Foundation Repair
Suppl. PC Fee: 0 Reg. ® OT 0.0 hrs $0.00 $815.00 IFOUNDREPA
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee Reg. 0 OT Q,p hrs $0.00 1 '
PME Unit Fee: $0.00 V
PME Permit Fee: $0.00
Cons0wetion Tnx:
Adinlnistrative Pee:
Work Without Permit? 0 Yes 0 No $0.00
Advanced Plannin&Fee: $0.00 Select a Non-Residential E)
Travel Do':ninentation Fees: Building or Structure ®�
Strom Motion Fee: IBSEISMICR $2.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $3.50 $815.00 TOTAL FEE: $818.50
3 Revised: 07/01/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CS M P IE R70 H QO Fax: 408-777-3333
CONTRACTOR SUBCONTRACTOR LEST
JOB ADDRESS: 1113— B /°� �� PERMIT#
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires alll] businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY I<NSPECT>ON(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPIERTI(NO
BUSINESS LICENSE.
>I am not using any subcontractor : D
S' nature ➢Date
?lease check applicable subcontractors and complete the following information:
V SUBCONTRACTOR RACTOR BUSI[NIESS NAME BUSffNIESS L><<CIENSIE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass /Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature ](Date