12010184CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18760 PENDERGAST AVE CONTRACTOR: HOLZER HEIDI M AND PERMIT NO: 12010184
NOROOZY HAMID
OWNER'S NAME:
CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDC " ELECT PLUMB
License Class Lic. #
MECH RESIDENTIAL COMMERCIAL
Contractor Date
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.
[ 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
t certify that I have read this application and state that the above information is
correct. l 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 pennit. 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code). ./v �l
I hereby affirm under penalty of perjury one of the following three
declarations:
l 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 wilt 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.
l 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
Municipal Code, Section
9.18.
Signatu Date
<<l l 12
JOB DESCRIPTION: REMOVE INTERIOR POST AND ADD NEW CEILING BEAM
Sq. Ft Floor Area: I Valuation: $8000
APN Number: 37527030.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAY ROM LAST CALLED INSPECTION.
IsZML 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 25505, 25533, and 25534.
Date: t(_� / \
I hereby affirm that there is a construction lending agency for the performance of "ork'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 Professional
,,��,�,�,,�—�� CITY OF CUPERTINO
I�9l FF,F. F,STIMATOR — BUILDING DIVISION
imADDRESS:
18760 pendergast ave.
DATE: 01/31/2012
REVIEWED B : bobs.
APN: _3 �7 030
1 BP#: ���0
"VALUATIO $0
`-PERMITTYPE: Building Permit PLAN CHECK TYPE: Alterati it
PRIMARY SFD or Duplex
USE:
PENTAMATION 1GENRES
PERMIT TYPE:
WORK
remove interior post and add new ceiling beam.
SCOPE
NOTE: This estimate 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 nrelininary information available and are only an estimate Contact the Dent for addh 7 info.
FEE ITEMS (F'ee Resolution 11-053 ff. 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F 1-1 #
$457.00
Close Existing Openings
1CLOSOPNIN Interior Wall
Suppl. PC Fee: D Reg. (0 OT
0.0 1
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg.
Q OT
0.0 1
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
;s •: •:
0
(F)
Work Without Permit? C) Yes (E) No
$0.00
Advanced Planning Fee:
$0.00
Selector Non -Residential
Building or Structure
G
Strong Motion. Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
.00
$457.00
TOTAL FEE:
1 $457.00
Revised: 1 /19/2012