11110164 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21230 HOMESTEAD RD CONTRACTOR:VILLAGE GREEN PERMIT NO: 11110164
ASSOCIATES
OWNER'S NAME: VILLAGE GREEN ASSOCIATES 130 E DANA ST DATE ISSUED: 11/29/2011
:R'S PHONE: 4082045367 MOUNTAIN VIEW,CA 94041.1508 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION r I—' r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.iYl
MECH r RESIDENTIAL(- COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:GAS TEST/GAS METER RELEASE(FIRE DAMAGE)
(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. Sq.Ft Floor Area: Valuation:$500
1 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, APN Number:32605085.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
Y P inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25.505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,sho d I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this conam
tinants i eBned by the Bay Area Air Quality Management District 1 will
permit is issued. maintain com once with the Cupertino Municipal Code,Chapter 9.12 and the
Health&SC ,Sections 25505,25533,and 25534.
1 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 Own or ent•
Compensation laws of California. If,after making this certificate of exemption,I _ Date: 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. CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
mfy milk eep humad the City of Cupertino against liabilities,judgments. ARCIIITF.CT'S DECLARATION
and expenses whi ay accrue against said City inconsequence of the
granting of this perm' it ally,[he applicant understands and will comply 1 understand my plans shall be used as public records,
with all non-point rc lotions per the Cupertino Municipal Code,Section
Licensed Professional
Signat, e Date l� /
• CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Slk: Lot:
APN . . . . . . . . : 32605085.00
DATE ISSUED. . . . . . . : 11/29/2011
RECEIPT #. . . . . . . . . : BS000015426
REFERENCE ID # . . . : 11110164
SITE ADDRESS . . . . . : 21230 HOMESTEAD RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : VILLAGE GREEN ASSOCIATES
ADDRESS . . . . . . . . . . : 130 E DANA ST
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94041-1508
RECEIVED FROM . . . . : MATTHEW LAGOE
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : VILLAGE GREEN ASSOCIATES
ADDRESS . . . . . . . . . . : 130 E DANA ST
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94041-1508
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 .00 41. 00 0.00 41. 00 0.00
1BCBSC VALUATION 500 .00 1. 00 0.00 1.00 0. 00
1BPGAS OULETS 1 .00 65.00 0.00 65 .00 0. 00
1BSEISMICR VALUATION 500 .00 0.50 0.00 0.50 0.00
1PPERMITFE FLAT RATE 1.00 44 . 00 0.00 44 . 00 0.00
1TRAVDOC FLAT RATE 1 .00 44 . 00 0.00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 195.50 0.00 195.50 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 195.50 MC
---------------
TOTAL RECEIPT 195.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
506 GAS TEST 507 FINAL PLUMBING
•
\ i it "Di Q-04
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
•CUPERTINO (408)777-3228•FAX(408)777-3333•buildine(cilcuoertino.orn MIS Vr
9flf6waING MECHANICAL EJELECMCAL EINIISCMLANEOUS
PROJECT ADDRESS 21210 -C" 5 5
✓ t�I
OWNER NAME t /I n dl' ✓�C/� N
�Re.e.� Arse PHONP4oFr2a�/-�367
STAEETADDRESS CITY, STA ZT? FAX
t3o cr• /a to e� unooA . a �.ye s"D• 96�`-32�
CONTACT NAMEA tf L A(Q btf PHV E-MAIL
STREETADDRESS CITY,STATE,ZI' FAX
❑ OWNER ❑ OWNER AGENT ❑ CONTaAOroa. ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEEIR ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHISELTM4GINEER NAME LICENSE NUMBER BUS.LIC#
COMFANYNAME' E-MAIL FAX '
STREET ADDRESS CITY.STATE,ZP PHONE
Ad L
SE OF ❑SFDwDUPLEC ❑ MULTI-FAMILY PROJECrINWILDLAND ❑ YESPROJECTIN ❑YES DTHERLOGAN El YES;
BUILDING: 13OOMMERCUA URBAN INTERFACE AREA C3 NO CsFLOOD ZONE No EICHLER HOME? [3 No
DESCRIPTION OF WORK / 0.S �ST WCL/`�✓ 'SLC '� �'�L.0
TOTAL VALUATION: RECEIVED BY;
.By Try Signature below,I certify to each of the following: I am the property owner or authorized agent to act an the property owner's behalf. I have read this
application and the infarmation I have provided is correctj have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection pLgases.
Signature ofApplicant/Agm Dem:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
W ❑ OYER-THE-COUNTER
6
❑ EXPRESS
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_ ❑ STANDARD
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❑ LARDE
Ilk 6
❑ MAJOR
A EPMJscApp 2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
tADD.RESS: 21230 homestead road DATE: 11129/2011 REVIEWED BY: larry s
BP#: "VALUATION: $500
`PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY Multi-Family Dwelling >31Stories O Yes (7 No PERMIT TY :ENTAMATION 1RPGAS
USE:
WORK as test/ as meter release
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1PGASRES 1 # $65
TOTALS: $65.00
tf,yh, Plmr Ch Plumb.Plan Check 0.0 hrs $0.00 Elea.Plan Check
:Meeh. Permit Fee.' Plumb.Permit Fee: IPPERM/T Flat. Pernd!fee:
• 011c, Itech./rep. Other Plumb Insp. 0.0 hrs $44.00 ptru;r Elea. Disp. Li
!lf,rrlt.lnwp. Fee: PIwsL. ln9p. 1 y EW'.InVP. Fee:
NOTE:This estimate does not Includefees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prefinina information available and are only an estimate. Contact the De t or addn7Into.
FEE ITEMS (Fee Resolution 11-053 Elf 7/1//1) FEE QTY/FEE MISC ITEMS
Plan Ch,!(A Fee:
.S9q�hl. F'C.P'ez
PME Plan Check: $0.00
Permit Fee:
,Suppl. Ittsp Fee
PME Unit Fee: $65.00
PME Permit Fee: $44.00
Construction nix
Administrative Fee: (ADMIN $41.00
Work Without Permit? O Yes 0 No $0.00
AdS aneed/Tanning Feer:
Travel Documentation Fee: ITRA VDOC $44.00
Shona Motion Fee: IBSEISkHCR $0.50 Select an Administrative Item
• Blde.Stds Commission Fee: IRCRSC $1.00
SUBTOTALS;i $195.50 $0.00 TOTAL FEE: $195.50
Revised: 10/01/2011