12090148CITY OF CUPERTINO BUILDING PERMIT
RUILDING ADDRESS: 11669 OLIVE SPRING CT
CONTRACI'OR: SGK HOME SOLUTIONS,
PERMIT N0: 12090148
INC.
OWNER'SNAME: ADAMS ROBERT A AND PATRICIA R
3801 CHARTER PARE: CT STE B
DA'Z'E ISSUED: 09/1812012
OWNER'S PHONE: 4082559707
SAN JOSE, CA 95136
PIIONE NO: (408) 264-6964
LICENSED CONTRACTOR'S DF,CLARATION
•108 DESCRIPTION: RF,SIDEN f1AL 11 COMDIERCIAI,
a
REMOVE AND REPLACE 3 WINDOWS AND 1 DOOR
License Class lC- Lia 9
Contractor - Date
I hereby affirm that I am I lensed trader the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the BusinesS 3 Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the fallowing 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
Sq. Ft Floor Area:
Valuation: 54100
performance of the stork for which this permit is issued.
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: 36654095.00
OccupancyType:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and slate that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all cityandcomity 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
p �i
Issued b J�/� �r/! �/ Dale: / �li /77granting
of this permit. Additionally, the applica t understands and will comply
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with all non -point source re ulations per the Cupertino Municipal Co Sect n
9.18.
/P
RF, -ROOFS:
,n/—
Signan. Date
All roofs shall be inspected prior to my roaring material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all newmaterials for
inspection.
❑ OWNER -BUILDER DECLARA'T'ION
Signature of Applicant: Date:
I heretic affirm that I am exempt from the Contractor's License Law for one of
the fallowing two reasons:
ALL ROOF COVF,RINGS •1'O BE CLASS "A" OR BETTER
1, as owner of the property, or my employees with %%ages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business R Professions Code)
1, as owner of property, am exclusively contracting with licensed contractors to
ILA"/„ARDOUS M ATERIALS DISCLOSURE
construct the project (Sec.7044, Business R Professions Code).
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safety Code, Sections 25505, 25533, and 25534. I will
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 S Safely Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate ofConseni to scl Linsure 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 llenlih S Safety Code. Seeti and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
V0533.
Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
ts;,
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 [,ENDING 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.
works far'which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICAYFCERTIFICATION
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 ordinanecs and slate 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.
graving 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
F����� ���� CITY OF CUPERTINO
"NI FEE ESTIMATOR - BUILDING DIVISION
NOTE: This eviinmte does not include jeer slue to otter Departments (i.e. Planning, Public. Il'orks, Fire, Sanitary Sewer District, Schon/
District. etc). These fees are based on the nreliminar , information available and are on/i, an estinmle. Contact the Dent for adt/n'I into.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11)
11669 OLIVE SPRING CT
DATE: 09/16/2012
REYIE�YED BY: Sean1AFikDDRESS:
Mech. Permit Fee:
APN:
BP#:
`VALUATION:
$4,100
*PERMIT TYPE: Building Permit
PLAN CIIECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Elec. Insp. ree:
PENTADIATION 1GENRES
PERMIT TYPE:
YORK
REMOVE AND REPLACE 3 WINDOWS AND 1 DOOR.
SCOPE
$0.00
NOTE: This eviinmte does not include jeer slue to otter Departments (i.e. Planning, Public. Il'orks, Fire, Sanitary Sewer District, Schon/
District. etc). These fees are based on the nreliminar , information available and are on/i, an estinmle. Contact the Dent for adt/n'I into.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11)
Alech, flan Check
Plumb. Plan Check
F.lec. Plan Check
Mech. Permit Fee:
Plumb. Permit Fee:
Mee. Permit ree:
Other Alech. lasp.
Other Plumb Insp.Li I
Other Elec. Inst,.
11e.ch. htsp. ree:
Plumb. hasp. ree:
Elec. Insp. ree:
NOTE: This eviinmte does not include jeer slue to otter Departments (i.e. Planning, Public. Il'orks, Fire, Sanitary Sewer District, Schon/
District. etc). These fees are based on the nreliminar , information available and are on/i, an estinmle. Contact the Dent for adt/n'I into.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$400.00
Window / Sliding Glass Door
1WINREP I Replacement
Suppl. PC Fee: Q Reg. O OT
FO.0
f hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Consiruction Tax.
Adinini tratice Ree:
0
0
Work Without Permit? O Yes Q) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
T _71Building or Structure
E)
0
i
Travel Documentation Fees:
Sunni, Motion Pee: /BSEIS,t11CR
$0.50
Select an Administrative Item
Bldg Sids Commission Pee: IBCBSC
$1.00
SUBTOTALS:
1 $1.50
$400.00
TOTAL FEE:
$401.50
Revised: 07/01/2012
Bldg fpp 2011.doc revised 06121/11
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