13030008CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10525 MIRA VISTA AVE
CONTRACTOR: TRACY HSU
PERMIT NO: 13030008
OWNER'S NAME:
CUPERTINO CA, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class Lic. #
HOUSE DEMOLOTIONS 1,552 SQFT
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
Sq. Ft Floor Area:
Valuation: $12000
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
APN Number: 35705039.00
Occupancy Type:
P Y
permit is issued.
APPLICANT CERTIFICATION
1 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
WI"T�IIN 1 0 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 DAY OM LAST CALLED INSPE TION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Date: /3
granting of this permit. Additionally, the applicant understands and will comply
Issued by:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature Date
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
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)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
l have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.I2 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
Section 3700 of the Labor Code, for the performance of the work for which this
the Health & Safety Code, Sections 25505, 25533,
Owner or authorized agent: ate
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 regulatio peLthe Cupertino Municipal Code, Section
Licensed Professional
9.18.
Date lJ013
Signature
CITY OF CUPERTINO D
FM,_1 FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10525 Mira Vista Road
DATE: 03/01/2013
REVIEWED BY: Sean
APN:
BP#: ��(��
"VALUATION: 1$12,000
PERMIT TYPE: Demolition Permit
PL N CHECK TYPE
PRIMARY SFD or Duplex
USE:
PENTAMATION 1SFDWL-DEM
PERMIT TYPE:
WORK
Demolition of existing SFD 1240 sq ft and garage 312 sq ft .
SCOPE
FEE ID FLR AREA
s.f.
1 DEMORES 1,552
,tech. Plan Check
Phunib, Plan ChecA
Flee. flan Check
:Lfec/1. PPYmit Fee:
Plrrmh. Permit Fee.
ITT, lec. Permir Fee:
Other A1ech. Insp.
01her Plumb Insp.Li
01her Elcc. Insp,
Mcch. Lrzip. Pee.
Phaub. hI.sp. Fee:
Elec Insp. Fee. -
NOTE. This estimate does not inchide fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eft' 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Chcck Fee:
Suppl. PC Fee
PlumbJjIllech./Flee
Permit Fee:
$534.00
Suppl. Insp. Fee Q Reg. Q OT
0.0
hrs
$0.00
Ph1mh./1ldech./Flee
PlumhJ,ifeeklElec: PermatT'ee:
Consiructiun .Tax:
Adminisirative Fee:
FVork Without Permit?
Advanced Planning Fees.
�
Travel Documentution Fees:
Strong* Motion Fee: IBSEISMICR
$1.20
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:;
1 $536.201
$0.00 TOTAL FF
6,20
Revised: 01 /01 /2013