06100072 CITY OF CUPERTINOGO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: SANTORO JERROLD PERMIT NO. 06100072,6100072
10450 PINEVILLE AV PERMIT ISSUE DATE
OWNER'S NAME:
SANTORO JERROLD SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
:Da1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Scction 7000)of Division 3 of thc Business and Professions Codc.and my license is 200 AMP UPGRADE
y in full force and effect
v�Z License Class Lic.S
Lo Date Contractor
I E ARCHITECT'S DECLARATION
�a< 1 understand my plans shall be used as public records
tyU
W to Licensed Professional
y OWNER-BUILDER DECLARATION
} 1 hereby affirm that 1 am exempt from the Contractors License Law for the
3 in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
82000
construct.alter,improve.demolish,or repair any structure
which requires a permit to cons
t 'y prior to its issuance,also requires the applicant for such permit to file a signed statementSq Ft.Floor Area
LiValuation
?< that he is licensed pursuant to the provisions of the Contractor's cense Law(Chapter 9
t=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
? that he is exempt therefrom and the basis for the alleged exemption.Any violation ofOccupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofaffr
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their salt compensation,
will do the work,and the structure is not intended or offered forsale(Sec.7044,Susiness Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
as owner of the property,am exclusively contracting with licensed contractors to
c I,truct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I xempt undoReee� _ B&P C fof thtrMason
w DateWOS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:,
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certifv that in the performance of the work for whjth this permit is issued,I shall not
employ any n in any man as tp 6cco •to tftc Workers'.tomnsation
Laws of Cr
tc
Applic N ELICANT: ,after making this Certificate of Exemption,you should
be me the Worker's Compensation provisions of the Labor Code,you mus
,J Z fo th comply with such provisions or this permit shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
Ft Cn 1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0 Lender's Address
1 certify that I 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 to
U building construction,and hereby authorise representatives of this city to enter upon the
above-mcnuoncd property for inspection purposes.
a (We)agree to save,indemnify and keep hornless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this it. / Date i
►�+ A LICANT UNDER DS IL...QQMP.LY WITH ACL NONPOINTIssued by:
RCE"T U A "t
Re-roofs
Yignature of Applicant Date
nYCf
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
fi
❑Yes No
rT If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes k]Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Safcty Codc,Sections 2 505,25533 and 25534.I understand that if thc building
d not curtcntly have a ani. atrjg �spQgsibility.to notify ocr�pant of the
iremcntswhich or an ofaCcnificatcof.' cu Signature of Applicant Date
ter . - All roof coverings to be Class"B"or better
Owner or authorize gent Date
CITY OF CUPERTINO
3m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # : 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36913037 . 00
DATE ISSUED. . . . . . . : 10/10/2006
RECEIPT # . . . . . . . • • : 36386
REFERENCE ID # . . . : 06100072
SITE ADDRESS . . . . . : 10450 PINEVILLE AV
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . : SANTORO JERROLD
ADDRESS . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : JERROLD SANTORO
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : SANTORO JERROLD
ADDRESS . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
------- ------ ---------- ---------- -----
BELEC200 METERS 1 . 00 29 . 43 0 . 00 29 . 43 0 . 00
BPERMFEE VALUATION 2 , 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BSEISMICRE VALUATION 2 , 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
--------- - ---------- ---------- ----------
TOTAL PERMIT 151 . 46 0 . 00 151 . 46 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
-- -- -- ---- - ----- - ------------ ------------------
OTHER 151 . 46 MASTERCARD
TOTAL RECEIPT 151 . 46
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. z'' All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
L.. er fa ..,a
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
performed
.................................................................................................................................................................................. .
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signaturer.
�` Date: D'
Job Address: r' -1-y\10 Permit#L,�U/-f ODe>—,--L
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
� f CITY OF CUPERTINO 1�
cuPE�-riNo PERMIT APPLICATION FORM
4PN# Date:
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor: License#:
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Descriptign:
Residential CJi�C��./t- Commercial El
Sq.Ft. Floor Area: q.Ft.:
Cwt of Proiect: Occupancv Group:
type of Construction: Please check this box if the project is a
second-story addition: ❑
'roject Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1-.75'M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax - BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC 1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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