14100113 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20678 SHELLY DR CONTRACTOR:SGK HOME SOLUTIONS, PERMIT NO: 14100113
INC.
OWNER'S NAME:
SAN JOSE,CA 95136 PHONE NO:(408)264-6964
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
F --� REMOVE AND REPLACE(8)WINDOWS AND(1)SLIDING
License Class ^C^ Tic.*4 r� / DOOR.
Contractor Date /
I hereby affirm 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 which this permit is issued. Sq.Ft Floor Area: Valuation:$6000
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 APN Number:35915003 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 City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued b � /v Al f Date: �U 'c-AQ '
granting of this permit. Additionally,the applicant understands and will comply y' „- -- - r
with all non-point source r ulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date O 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 I 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 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
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,Section4550Se25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent Date: V
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 mentioned 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 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
t/L%1D0113
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO 1 (408)777-3228•FAX(408)777-3333•building(cDcupertino.oro
❑NEW CONSTRUCTION E1ADDinoNr 2ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS APN# /� n0
OWNERNAME
/STREET ADDRESS /� e CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAM!S e LICENSE NUMBE>i� jr'� LICE TYKE/ BUS.LIC#
COMPANY NAME C v�►/rl �( / Z E-MAH, / o "(J FAX
STREET ADDRESS� ICTT Y T
ARCHITECT/ENGINEERNRME /) LICENSE NUMBER BUS.LIC#�/�
COMPANY NAME �" E-MAIL FAX
STREET ADDRESS CI'T'Y,STATE,ZIP PHONE
DESCRIPTION OF WORK c
EXISTING USE PROPOSED USE CONSTR.TYPE I #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA I DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: BDETACH
ATTACH
#DWELLING UMTS: IS A SECOND UNIT YES SECOND STORY YES
BEINGADDED? ONO ADDITION? NO
PRE-APPLTCATTON DYES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES "'RECEIVE Y: TQTAL VALUATION:
PLANNING ADPL# Q NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NOc�-
By my signature below,I certify to each ofAit following: I am the property owner or authorized agent to act on the property owner's behalf I have read this
application and the information I have d' c ct. I have read the Description of Work and verify it is accurate. I a 'Ice to complywith all applicable local
ordinances and state laws relating to ction. I authorize representatives of Cupertino to enter the above-id ' e/ p for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATI REQUIRED PLAN CHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ovErs=rilE-covNTER avn DnvG PLAN ISEvmw
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. :EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure b:`STANDARD ElPtMLIC WORKS
form if any Hazardous Materials are being used as part of this project. [j LARGE ❑ F1tE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to t
El MAJOR El SANrlARYSEWERDISTRICT
submittal of Building Permit application.
❑ ErrvmoNMMAL HEALTH
BldgApp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20678 Shelly Dr DATE: 10/20/2014 REVIEWED BY: Sean
APN: BP#: "VALUATION: 1$6,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex PENTAMATION 1GENRES
USE: p PERMIT TYPE: i
WORK Remove and replace 8 windows and 1 sliding door.
SCOPE
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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 prelimina information available and are onl an estimate. Contact the Dept-for addn'l info.
FEE ITEMS (Fee Resolution 11-053 U. 711/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Window/Sliding Glass Door
Suppl. PC Fee: (j) Reg. 0 OT 0.0 1 hr's $0.00 $574.00 IWINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
(cirnrri,;rrfrri e. `'c't': 0
Work Without Permit? ® Yes Q) No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential
l/)cxarrrr�zs�rl�t>rt /�'e;�-s: Building or Structure 0
Travel i
Strong Motion Fee: 1BSEISMICR $0.78 Select an Administrative Item
Bldy_Stds Commission.Fee: IBCBSC $1.00
$1.78 $574.00 TOTAL FE: $575.78
Revised: 07/10/2014
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Name:
Address: 2 -72 /-'.*2
Email: �v
Phone: l — 6 4 O J- i IOMC—St3L13T10NS
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Off: 408-264-6964 www.sgkhomesolutions.com Fax: 408-264-6126