12090147CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10117 STERN AVE CONTRACTOR: DWK CONSTRUCTION PERMIT NO: 12090147
OWNER'S NAME:
CUPERTINO, CA 95014 T PRONE NO: (408) 996-1186
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lic. # 2-2-0o ,%
Contractor St/Zp di -ft pate Z
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.
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
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
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. yI
Signature !/` 2 Date /0 — 2 q — / L
14
❑ 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 (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 1 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
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: SFDWL DEMOLITION (1,034 SQFT)
Sq. R Floor Area: I Valuation: $8000
APN Number: 37511059.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:� Date:/0 C7y7C
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
1 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 1 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• % c'� -- �. � / Z
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of Hork's
for which this permit is issued (Sec. 3097, Civ C.)
Leader's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
JIMffAP
DRESS: 10117 stern ave DATE: 09/17/2012
REVIEWED BY: larrys
Plumb. Plan Check
:
BP#:
'VALUATION: 1$8,000
*PERMIT TYPE: Demolition Permit
P1 -4N CIIECK TYPE:
PRIMARY SFD or Duplex
USE:
Otber Elec. lnsp. Li
PENTAMATION 1SFDWL-DEM
PERMIT TYPE:
WORK
demo
SCOPE
$534.00
FEE ID FLR AREA
s.f.
1 DEMORES 1,034
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/11)
FEE
,ifech. Plan Check
Plumb. Plan Check
Elec. Plan Check
d9ech. Permit Fee:
Ph.rmb. Permit Fee:
Elec. Permit Fee:
Other ;llech. Insp.
Other Plumh Insp.
Otber Elec. lnsp. Li
11ech. Insp. Pee.
Phunb, lisp. Fee.
Glee. Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Chuck Fee:
Suppl. PC Fee
P1umb.1,We c:lz.; Elec
Permit Fee:
$534.00
Suppl. Insp. Fee -0 Reg. Q OT
0,0hrs
$0.00
Plumb./sllec/I.;Elec
P/urrzh.!Alec/z.;Elec Permit Fee:
COIISIMetion Tai-:
Administrative .Fee:
lVork. Without Permit?
Advanced Planning Fees:
Travel Documentation Fees:
Strong Motion Fee: 1BSEISMICR
$0.80
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$535.80
$0.00 TOTAL FEE$$535.80
Revised: 07/01/2012