12090063CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21869 GARDENVIEW LN CONTRACTOR: RANDAZZO PERMIT NO: 12090063
DESCRIPTION: RESIDENTIAL LJ COMMERCIAL
License Class Lic. N SINGLE FAMILY RESIDENTIAL DEMOLITION
1100 SQ FT HOUSE, 400 SQ FT GARAGE
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 whichthis permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for die 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 non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Sq. Ft Floor Area: I Valuation: $14200
APN Number: 32619087.00 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: ��9/✓]rG�7 Date:
RE -ROOFS:
Date All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, 1 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
the following two reasons:
1, 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.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for die 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, 1
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. A
Jditionally, the applicant understands and will comply
with all non -point sour re ulations per the Cupertino Municipal Code, Section
9.18.
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. 1 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 Cupert unicipal Code, Chapter 9.12 and
the Health & Safety Code, Sections W , 255 3, and 25534.
Owner or authorized agent: Date:
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
Date Q 11 2u1 L
FM-7
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: �l��p
DATE:
REVIEWED BY:
APN: I
BP#: G) on
-VALUATION:
1$14,200
PERMIT TYPE: Demolition Permit
PLAN CHECK TYPE
PRIMARY SFD or Duplex
USE:
ENTAMATION 1SFDWL-DEM
7PERMITTYPE:
WORK
qktWo
SCOPE
FEE ID FLR AREA
s.f.
1 DEMORES 1,500
fcch. Plan Check
Plumb, Plan Cheek Elec. Plan Check
IVIech. Peron! Fee:
Phamh. Permit Fee: Dec, Permit Fec.
rllech. Insp.
L
Other Plumb Insp. Other Elec. lnsp..
Insp. Fee:
Plumb. hr.cp. Fee: Elcc, 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 Dreliminary information available and are only an estimate Contact the DeDt for addn'l info.
FEE ITEMS (Fee Resolution II-053 Eff 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC F'ec
Plumb.;Rleclz;Elec
Permit Fee:
$534.00
Suppl. Insp. Fee-0 Reg. ® OT
F070
hrs
$0.00
Plumb.iRlech./Elec
Plumh.AAfeclt./Elec Permit fee:
Consltwclion 1-try:
Adininistralive Fee.
[York ffithoutPermlt%
Advanced Plctrming Feces:
A
Travel Docnin-entation Fees.
Strong; Motion Fee: IBSEISMICR
$1.42
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $536.421
$0.00
TOTAL FEE:
$536.42
Revised: 07/01 /2012