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11070068 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22721 MEDINA LN CONTRACTOR:ANTIQUE TERMITE PERMIT NO: 11070068 & PEST ^WNER'S NAME: MBR LLC 1913 STONE AVE DATE ISSUED:07/12/2011 . WNER'S PHONE: 6507043355 - SAN JOSE, CA 95125 PHONE NO:(408)995-6300 LICENSED CONTRACTOR'S DECLARATION i� F� / BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.4 k%. `, s=7�'�i� i 1 . MECEI RESIDENTIAL COMMERCIAL Contractor 'J� 4�d�+�,��.�- Date 1 hereby affirm tha I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: UNIT B-'I'ERMI"f F"DAMAGE REPAIR IN BATHROOM SHOWER (commencing with Section 7000)of Division 3 of the Business&Professions AREA ONLY,REPLACE VALVES,DRAIN WATER RESISTANT Code and that my license is in full force and effect. BACKING BOARD,RF"-TILE,FINISH 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. Sq.Ft Floor Area: Valuation:$5300 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 whiis APN Number:34230003.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I 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 WITHIN 180 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the ity of Cupertino against liabilities,judgments, costs,and exp,nses hich may ac ue jain st said City in consequence of the �/-�Issued b - — a- Date:�'lgranting of th' perr(ryt. Additiona ,tplicant understands and will comply Ywith all non-0, int sq ce regulatio pCupertino Municipal Code,Section 9.18. ; v '= RE-ROOFS: nature Date t t' 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant Date: 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). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous 1 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(luality Management District I performance of the work for which this permit is issued. will maintain compliance with the 'up rtino Mu cipal Code,Chapter 9.12 and the Health&Safety Code,Sectio 25 5,25533, r d' 5534. I have and will maintain Worker's Compensation Insurance,as provided for by y �-- Section 3700 of the Labor Code,for the performance of the work for which this - � permit is issued. gent: Date: Owner or authorized a ( y 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 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 t the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION mnify and keep harmless the City of Cupertino against liabilities,judgments, 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 regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date PROJECT DATA - RESIDENTIAL, COMMUNITY DEVELOPMENT DEPART41N� N D $ION "\ 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 � � (408)777-3228• FAX(408)777-3333•building(8cugertino.org PROJECT ADDRESS �✓/ "'f'� y APN# OWNER NAMEI1ONE s STREET ADDRESS �� �, I ,.CITY, STATE,ZIP �y FAX . rl APPLICANT NAME r- 0�1F , . E-MAIL kq STREET ADDRESS ` L, CITY,STATE, ZIP FAX 1--(o '.�) 7 ��`_>LZ/� � ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT DESCRIPTION OF WORKI VA d co . EXISTING USE(S): PROPOSED USE(S): — OCCUPANCY(S): TYPE OF �� , PARCEL �� `��'� �1'`l —� CONSTRUCTION:1 v' x:J��'A � AREA: FIRE SPRINKLERS: Y WUI AREA: Y l N/ FLOOD AREA: Y N SIESMIC AREA: Y�t N Existing Proposed '-�k Floor Area: First Floor: "� t- - s.f s.f. Second Floor: f. ss.f. Garage s.f s.f. \_ TOTAL: s.E ' s.f. Are there at least two 10 feet by 20 feet clear spaces inside the garage? � N Is privacy protection planting required for the project? Y �N� COIVIl45l"1�1'?'�DRTLOPMTNT DFPARTMEN ' iL it V` " T Governing Codes: 2010 California Building Code(based on the 2009 Intematlona� Ilg' 4p�H fINrJ 2010 California Residential Code(based on the 2009 InternatiQ"*F4 "L112yde) 2010 California Plumbing Code(based on th t4®®fit fl R� ro'nZ.rode) 2010 California Mechanical Code(based on ItWOST he keit at the Varfuul to r.�al;, any 2010 California Electrical Code(based on the 2099 I it a[tac J, j�Ft�u�C�S AQ or,to Zvi re the rt;rr�, vvi 2010 California Energy Code X130`-� 2010 California Green Building Standards approval from the Building Gfficial. 4'��;taf�,r�'nr°c'this Clan anc<specifications SHALL NOT Cupertino Municipal Code hen alt.;o t,<<3r it or tr, - bo do approval of the violation of an; provisions of any City Ordinance or State Law. BY 42� DAi:F -l2 _ c, PERMIT NO. U ProjectData-Rest-0707.'M 09/11 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# 110 v OWNER'S NAME: PHONE # &'-X') GENERAL CONTRACTOR: BUSINESS LICENSE # L�'c-) e�e'-2- ADDRESS: i,4- CITY/ZIPCODE: *Our municipal code requires all busines es working in th city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL O CU ANCY IN ECT ON(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUB ONT RS AVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. IN I am not using any subcontractors: ature Date Please check applicable subcontractors an m to the following information: j/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . . 34230003 . 00 DATE ISSUED. . . . . . . : 07/12/2011 RECEIPT # . . . . . . . . . : BS000014019 REFERENCE ID # . . . : 11070068 SITE ADDRESS . . . . . : 22721 MEDINA LN SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . MBR LLC ADDRESS . . . . . . . . . . : 22721 MEDINA LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ANTIQUE TERMITE CONTRACTOR . . . . . . . : MICHAEL R MEEK LIC # 24455 COMPANY . . . . . . . . . . : ANTIQUE TERMITE & PEST ADDRESS . . . . . . . . . . : 1913 STONE AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 TELEPHONE . . . . . . . . : (408) 995-6300 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 5, 300 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 5, 300 . 00 0 .53 0 . 00 0 . 53 0 . 00 1STINSP UNITS 3 . 00 390 . 00 0 . 00 390 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 391 . 53 0 . 00 391 . 53 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 391 . 53 12451 --------------- TOTAL RECEIPT 391 . 53 CONSTRUCTION PERMIT APPLICATION [1 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228-.FAX(408)777-3333• building cDcupertino.org {0-_7W ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS� -121 �C'(71r�� ' ��`y; APN# .3LI2 3b "�(vl��3 . OWNER NAME l 1 � 4?v /J n.����'� E-MAIL STREET ADDRESS ", CS,TY, STATE,ZIP FAX CONTACT NAME /' ` PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 1 LSCSE NI ER 1 LICENSE E BUS.LIC)? COMPANY NAME E-MAIL '1AX STREET ADDRESS P'� 1 CI,Y,STATE,ZIP P ON. ARCHITECT/ENGINEER NAME LICENSE NUMBER BUTS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE _)ESCRIPTION OF WORK �G't I/1G'� CJ U IVB- EXISTING USE PROPOSED L�,t CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION'S) EXIST NEW FLOOR DEMO TOTAL AREA AREA AREA NET.4REA AD BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: 9ETACH ATTACH #DWELLING UNITS: IS A SECOND UNIT _0 YES SECOND STORY [:]YES BEING ADDED? JZko ADDITION? NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOT A VALUATI i PLANNING APPL# Lpie- PLANNING PROVAL LETTER EI HLER HOME? 0i s � L' By my signature below,I certify toLofllowing: Aau p perty owner or authorized agent to act on the prrperty owner's behalf. I have read this application and the information I hcorrect. ea the Description of Work and verify it is accurate. i agree to comply with all applicable local ordinances and state laws relating structioriz repr sentatives of Cupertino to enter the abIve-ide tified property for inspection purposes. Signature of Applicant/Agent: Date: �� �` SUPPLEMENTAL ORMV. IO REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwelling Apply or demolition permit for �'SVR TAE-couNTER B +ING PLAN REVIEW existing building(s). Demolition permit I �e Ired prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Comunercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11