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13040080 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10230 VICKSBURG CT CONTRACTO PERMIT NO:13040080 D] vfBIEH— OWNER'S NAME:.HIDEYUKI ARrFA' ` DATE ISSUED:04/09/2013 OWNER'S PHONE: 4082558497 PHONE NO: [3 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL S COMMERCIAL License Class_ Lic.# 3 2 2/ TO CLEAR CODE ENFORCEMENT CASE:ADD ONE /! LIGHT TO Contractor ZP s (4&t-A,-&,' l ol,cY Date 4-10712-01? GARAGE DOOR(NOT TO ILLUMINATE TO I hereby affirm that I am licensed under the,provisions of Chapter 9 NEIGHBORING (commencing with Section 7000)of Division.3 of the Business&Professions PARCELS) 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. Sq.Ft Floor Area: Valuation:$1000 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:36914013.00 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 WIT80 AYS 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 DA F OM LAST CALLED INSPECT ON. indemnify and keep harmless the City of Cupeitino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the 6j granting of this.permit: Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 7-4 RE-ROOFS: Signature . Date O L��3 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.1 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 ownerr,of the property.;or my employees with wages as their sole compensation, will do the work'and the!structure'i's'not intendedor 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(Seo 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 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 the Health&Safety Code,Sectio 505,25533, nd 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ageate! ' 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 rrientioned.property,for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify 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.penmt.I Additionally,the applicant-understands and will comply with all'non-point sour.6c regulation per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION C/v .10300 TORRE AVENUE•CUPERTINO,CA 950143255 CE PERTIFI© (408)777-3228• FAX(408)777-3333• building(a-)cuoertino.org MISC ❑PLUMBING ❑MECHANICAL LKELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS /"0.23 O 1 I i a )(5 6U i. C% APN n O' OV NER NAME �I /\ G��I PHONE _ E-MAIL STREET ADDRESS , ,Z FAX � �s6ur c- CITYSTATE � ��c i�/ CONTACT NAME PHO E-MAIL STREET S CITYSTA ,ZIP FAX 0 /N A/5 ri L , - n!v ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTR.An NAME LICENSE NUMBER LICENSE TYPE BUS.LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTIENGLNTEER NAME LI SE NUMBER BUS.LIC# COMPANY NAME' E-MAIL. FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD.DUPLEX ❑ maTI-FAMII.Y PROJECT IN WILDLAND ❑ YES [7ZROJECTIN ElYES IS THE BLDG AN ❑YES BUILDING: COMMERCIAL URBAN INTERFACE AREA ❑ NO OD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK cue L TOTAL VALUATION: (0 0(,/I I� RECEIV'ED BY: By my signature below,I certify to each of the following: I am th rty owner or authorized agent to act on th pr rty owner's behalf. I have read this application and the information I have provided is correct. I b read a Description of Work and verify it is accura . I agree to comply with all applicable local ordinances and state laws relating to buildi on ze representatives of Cupertino to enter the above-Identified propel` for inspection pulposes. Signature of Applicant/Agent: Date: r✓ SUPPLEMENTAL INFORMATION REQU�tED OFFICE USE ONLY OVER-THE-COUNTER ❑ ExPRESS U ❑ STANDARD U ❑ LARGE ❑ MAJOR 1EP.4&c,4pp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10230 vicksburg ct DATE: 04/09/2013 REVIEWED BY: Mendez APN: BP#: EVALUATION: $1,000 *.PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY PENTAMATION 1 REAP10 USE: SFD or Duplex PERMIT TYPE: i WORK To Clear Code Enforcement Case: SCOPE u. �1ecb..F'Care Check PCutrrb,Ptah Check Elec.Plan Check 0.0 hrs $0.00 ifech.Perrtait Fee: PCumb.Permit Pee: Elec.Permit Fee: IEPERMIT _L_ Other :llech.Insp. Oilier Plumb Insp. Li Other Elec.Insp. 0.0 �s $45_00 lAllech.Inds. Fee: Plumb. hasp.Fee: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(i e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These fees are based on the prefindna information available and are only an estimate- Contact the Dept for addn'1 info, FEE ITEMS (Fee Resolution 11-053 E f 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # Electrical Suppl.PC Fee: (D Reg. ® OT 0.0 hrs $0.00 $45.00 1BREMRECEP Recep/Switch/Outlets PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee-.0 Reg. '0 OT. p,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00. Co nstruction :Tera: FA Administrative Fee: IADAffN $42.00 Work Without Permit? Yes ® No $135.00 G Advanced Planning Fee $0.00 Select a Non-Residential .0 Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure ®� Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC 1 $1.00 $268.50 $45.00 $313.50 . " Revised: 04/01/2013