11020093 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22595 POPPY DR CONTRACTOR:BROTHERS HOME PERMIT NO: 11020093
IMPROVEMENT
OWNER'S NAME: FOREMAN JERRIE 2510 DOUGLAS BLVD DATE ISSUED:02/24/2011
C BR'S PHONE: 4089961851 ROSEVILLE,CA 95661 PHONE NO:(408)295-0680
ay LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG[_ ELECT r— PLUMB
License Class Lic.#
fof MECH F RESIDENTIAL r COMMERCIAL
Contractor Date Z l
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:6 WINDOWS&2 PATIO DOORS LIKE FOR LIKE RETRO-FIT
(commencing with Section 7000)of Division 3 of the Business&Professions INSTALL;NON STRUCTURAL
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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$5372
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:34212056.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the a icant understands and will comply
with all non-point source egulations per a Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date Z
G OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I 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
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safe Code, ections 25505,25533,and 25534.
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 Owner Whor' ed agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
it nify and keep harmless the City of Cupertino against liabilities,judgments,
And expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34212056 . 00
DATE ISSUED. . . . . . . : 02/24/2011
RECEIPT #. . . . . . . . . BS000012763
REFERENCE ID # . . . 11020093
SITE ADDRESS . . . . . : 22595 POPPY DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : FOREMAN JERRIE
ADDRESS 22595 POPPY DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-0802
RECEIVED FROM . . . . : SEAN FERGUSON
CONTRACTOR . . . . . . . : GENE V. CAVANNA LIC # 27964
COMPANY BROTHERS HOME IMPROVEMENT
ADDRESS . 2510 DOUGLAS BLVD
CITY/STATE/ZIP . . . : ROSEVILLE, CA 95661
TELEPHONE . . . . . . . . : (408) 295-0680
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 372 . 00 1. 00 0 .00 1. 00 0 . 00
1BSEISMICR VALUATION 5, 372 . 00 0. 54 0 . 00 0 .54 0. 00
1WINREP EACH 8 6 .00 380 . 00 0 . 00 380 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 381 .54 0 . 00 381 . 54 0 . 00
J
a
r (qj.TA
'lob N 113)
.terry rt EdA+e-
Or
CA
eL
civ +ci. c "e- -
(frw��ws�
B,.W\
Building Department
City Of Cupertino
La 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 2 c r• PERMIT#
OWNER'S NAME: rrl (� ' ✓Yho PHONE#
GENERAL CONTRACTOR: �„r�, p� 4 BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE: Sart TOst tj fi-)Z/T-
I
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY I PECCTORTION(S ILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCON S H OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
� yh//
Owner/Contractor Sinature Date
CITY OF
CITY OF CUPERTINO
GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
APN# c.._�' ( Date: l
Building Address:
Mailing Address (if different from building add e s):
Are Hazardous Materials being used as paVif
s project? Yes El No
HOA: (Exterior work only) Yes E] No yes, provide letter from HOA
If Residential.is house an Eichler? Yes ❑ No If yes, needs planning approval.
Own "Name: Phone#: 0p// _
«� ll0
Contractor: Phone: /-- ('00— 74 3 7 7,->
/2)rA(6 Fax:
Contractor License
Cupertino Business License
Contact: Phone:
Fax/e-mail: '
Residential Comraircial ❑
Job Description:
�G►�
Building Perm' Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B ❑
Valuation: � � Z � p a Square Footage:
Project Size: Counter ❑ Ex ress ❑ Standard Lar e ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved: G
For help, contact Build it Green at www.buildit reen.or
Revised 12/06/10