12100077 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10230JOlINSONAVE CON'1'RACI'OR:NGUYEN JENNIFER PERMIT'NO: 12100077
OWNER'SNAMIi: NGUYENIENNIFER 10230.I0IINSONAVIi DA'Z'E ISSUED: 10/102012
OWNER'S PHONE: 6505737333 CUPERI'INO.CA 95014 1'110NENO:
❑ LICENSED CON T'RACTOR'S DECLARATION BUILDING PERDIITINFO: BLDG r ELECT Cl PLUMB C
License Class Lie.H
D1ECfl - RESIDENTIAL ' 1 COMMERCIAL ')
Contractor Date
I beech)affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE INTERIM WALLS(NON-LOAD BEARING)
(commencing with Section 7000)of Division 3 of the Business& Professions UNPERMITrED
Code and that my license is in full farce and effect. WALLS,TO RESTORE PROPERTY TO ORIGINAL PERMITTED
STATE_595 SOFT
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
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.R Floor Area: Valuation:$100
\I'1'I,IC.\\1'CFR'I'1 FIG\TION
I certify that I have read this application and state that the above information is APN Number:37525063.00 OccupancyType:
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
graming of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DA .S FROM AST CALLED INSPECTION.
9.18. C�,T_"_
Signature Date Issued by: •/0 Date:
/1. OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contraelor's License Lay for one of RF.ROOF'S:
the following ton reasons: All roofs shall be Inspected prior f0 any roofing material beltgInstalled.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sce.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjuq one of the follmving three ALL ROOF COVERINGS TO BE CLASS"A"OR BE'1-1'ER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's IL\"/,ARDOUS MATERIALS DISCLOSURE
Compensation,m provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California llealth J Safety Code.Sections 25505.25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the llealth S
Safety Code.Section.553..(1)should I store or handle hazardous material.
permit is issued Additionally,.should 1 use equipment or devices which emit hazardous air
I certify that in the performance of the work forwhich this permit is issued,1 shall contaminants as defined by the Bay Area Air QualityManagement District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance wish the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws orCalifomia, If,after making this certificate of exemption.I llealth S Safety Code,Sections 2550.5,25533,and 25534.
became subject to the Worker's Compensation provisions of the Labor Code,I must '/
forthwith comply with such provisions or this permit shall be deemed revoked Owner�hgent: `/ 02
// Datc: // G
AI'1'I,ICANT'CER-1'1F1CAT'10N CONST'Rl1CITON LENDING AGENCY
I certify that I have read this application arid state that the above information is
correct.I agree to comply with all cit and count ordinances and state lass relating I hereby affirm that there is a construction lending agency for the perfommnce of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Cir C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilitics,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ,\KCI I I'1'ECI"S DECLARATION9.18.
O I understand my plans shall be used as public records.
Signature/ Date �4
Licensed Professional
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
- 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•'FAX(408)777-3333• building(5),cuoertino.oro
PROJECT ADDRESS loe,2 3Q JbHN�N / 1(/r APN 0,
OWNER NAME (/LL/41-7
STREET ADDRESS IVJ/•, CITY STA E- FAX
,705 Ar &1/v SAN urr�a
CONTACT NAME PHONE lv E-MAIL
/LC //9h F/11fh
STREET ADDRESS CITY,STATE,ZIP FAX
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑LNGIN�R ❑ D ER ❑TENAM
CONTRACT LICENSENUMBER LICENSETYPE BUS,LTC4
CO.'DANY NAME E-MA FAX
STREET ADDRESS CITY,STATE,ZIP NE -
DESCRIPTION OF W'ORx N0�`ZO
YI�F'/0 U � .� 4/oH k/' L FlIO &EALPI.✓ l/iV QE2M/TT�1J
RESIDENTIAL ZS9S 0DWELLWG 011FICEUSEONLY
FLOOR AREA UNITS USE Orr: TYPE' ^saA i Nr
COALMERCIAL
FLOOR A
TYPE OF CONSTRUCTION MSTORIES - ,
AQMDIOB NUMBER RECEIVED BI': TOTAL VALUATION:
By my signature below,1 certify to each of the 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 1 have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating w building consuuction, authorize represenmtives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agen Date:
SUPPLEMENTAL INFORMATION REQUIRED PRIOR-I'0 ISSUANCE OF DEMOLITION PERMIT OFITce use ONLY
_Provide Job Number from Bay Area Air Quality Management District wu%v.baaumd.org rr 415-749-4762. - _PLAs cuEcK T PE -
_Provide three copies of a site plan showing protection for any trees 10"in diameter or more at 3'above grade. LXPResS '•r
_Provide letter from PG&E(408-725-3325)stating all gas and electric has been disconnected. El�STdNp"�RD
_Provide a letter of inspection,tests,and abatement of any Hazardous Materials.Letter to be initiated by person(s) I-ARCS; F,
certified in asbestos,mercury and/or hazardous material examination. El %IAJOai- :•I
_Planning Dept clearance to verify building is not considered an historical landmark.AIImY Ill business days. _ ' "• ' �
_Provide letter of clearance of all vermin from a licensed pest control contractor.
_Applicant shall call the Public Works Department at 408-777-3104 and schedule a"habitable dwelling"inspection. '' x
_Provide signed Debris Bin and Recyclable Materials form. • '� r
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression/alamL system review.
Demodpp_2016doc revised 03� /16/11
CITY OF CUPERTINO D
FEE ESTIMATOR - BUILDING DIVISION
12 ADDRESS: 10230 johnson ave DATE: 77 REVIEWED BY: larrys
APN: BP#: 'VALUATION: $100
`PERMITTYPE: Demolition Permit PL,INCllr:CKTYPE:
PRIMARY SFD or Duplex PENTAMATION 1SFDWL-DEM
USE: PERMIT TYPE:
NVORK
SCOPE
FEE ID FLR AREA
s.1.
1DEMORES 2,565
Meth. Plan Check Plumb. Plan Check Eke. Poon Check
blech. Permit Fee: Plnmh. Permit Fac: Efec. Permit Fee:
Ober Afech. lnrp. Odter Plumb lnsp. Other Ele.c. Inst'. El
.Neth.Guy.Fec: Plumb. htsp.Fee: Elce. Insp.Fee:
NOTE: This estimate does tot include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). These feev are baser/on lite prelintinan information available and are only an estimate. Contact the De t or adebt'I info.
FEE ITEMS (Fee Resolution 11-053 EB' LL! I21 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
,Suppl. PC Fec
Plunth.htfech./F.lec
Permit Fee: $534.00
Suppl. Insp. Fee,0 Reg. Q OT 0,0 hrs $0.00
Phnnb.11feeklElec
P1umhJA-fech./E1ec Permit Fee:
Consnvtction Tax:
Administrative Fee:
Work Without Permit?
Advanced Planting Fees:
Trovel Doctuncniation Fees:
Strove Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $535.50 $0.00 TOTAL FEE: $535.50
Revised: 10/01/2012