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12100180 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS; 10313DEGASCT CO\I'RACI'OR:RAVANAGI'I PERMIT'NO: 12100180 CONSTRUCTION CO. OWNER'S NAME: RANDALL CONCETrA M TRUS'T'EE 2221 MORA DR DATE. ISSUED: 10242012 OWNER'S PHONE: 4087300960 MOUNTAIN VIEW.CA 94040 Pl IONE NO:(650)964-1640 ❑ LICENSED CO\ RACTO�-R'�S DECLARATION' BUILDING PERMIT INFO: BLDG (- ELECT r PLUMB ri License Class Lie.N "�L1�27`1 /I '' OIECHr RESIDENTIAL r__J COMMERCIAL r L Conlmctor ( C Otv�)ate Y ( JOB DESCRIPTION: UNITS A&BAEMOVE AND REPLACE(IO)WINDOWS AND hereby affirm that I am licensed under t e provisions of Chapter 9 (3)PATIO DOORS (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a ceniBcate 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 forwhich this Sq.Ft Floor Area: Valuation:$7700 permit is issued. API'I.ICAN'TCER'1'I17IC,\'['ION APN Number:34230026.00 OccupancyType: I certify that thrive read this application and state(hat the above information is ' correct. I agree to comply with all city and county ordinances and state Imus 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,andcspenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understandsand will comply 180 DAYS FROM LAST CALLED INSPECTION, with all non-point source regulations per the Cupertino Municipal Code,Section Signature Cmt,-Z� Date f). 2' / Issued by: ��/� �G� Date:�� t.7 � 1-1 ❑ OWNER-BUILDER DECLARATION Rh:ROOFS: hereby affirm that I am exempt from the Contractor's License Law for mw of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining ma inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sce.7044, Business&Professions Code) Signature of Applicant: Date: I,m owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code), ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER hereby nfLrm under penalty of perjury one of the fallowing three declarations:, I have and will maintain a Certificate of Consent to self insure for Worker's IIA%ARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Ileal(h&Safety Code,Sections 25505.25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilcalth& Section 3700 of the Labor Code,for the performance of the work for which this Safety Coda Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Ray Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I Shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Surety Code,Sections 25505,25533,and 25534. Compensation Imus of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Owner o/a'authorizc a�em. forthwith comply with such provisions or this permit shall be deemed revoked. -^'1.'��'�'�""^,""G�`De[e: /nom/oL APPLICANT CERT'IFICA'TION CONST'RUC-FION LENDING AGENCY I eer(ifv that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's cored.I agreeto comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ,yR(:III'I'FCI"S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand nay plans shall be used-as public records. Signature Date Licensed Professional *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PENTAMATION 1GENRES USE: PERMITTYPE:PRIDARY SFD or Duplex Al CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO,CAA95014-3255 GUPERTINO (408)777-3228• FAX(408)777-3333•building0cupertino.oro ❑NEW CONSTRUCTION El ADDITION 52 ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAI,PERMIT# PROJECT ADDRESS APNN y�. - 30 •oa OWNER NAME 77?1 119 PHOS 0 —7LJ0 -O E-h1AIL STREET ADDRESS CITY, [•ATF.,ZIP FAX CONTACT NAME jr I ' PI{0 ' E;l1AIL LIC Ca7^—F STREETADDRESs I C STATT ZIP FAX —/ ❑ON:\ER ❑ OWNER-BUILDER ❑ OWNIERAGG\T G CONTRACTOR ❑CONTRACTORAGE\T ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NMJE LICE,' NUMBER LICENSETYPE BUS.LICM COMPANYNA. E E-h IL FAX s wig VA STREET ADDR S STATP Z P po ARCOMECT/ENGINEER NAME 0 LA LICENSE NUMBER BUS.LIC N COMPANY NANIE E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIMON OF WORK C / EXISTNG USEIDECKA"� PROPOSED USE CON5111.T'PE MSTO IES �� USE TYPE OCC. SQ.PT. VALUATION(5) EVISTG BOOR DEMO TOTAL AREA AREA NET AREA BATHROOMKDCHEN OTHER REMODEL AREAREMODEL A0.EA REMODEL AREA PORCHAREA TOTALDECK FORCHAREA GARAGEAREA' DETACH❑ATTACH F DWELLING UNITISASECONDUNITSECOSNDora ❑YES BEING ADDED: . NOFS ADDITION: 0$0 PRE-APPLICATON ❑Y IF l'ES,PROVIDE COPY OF IN TIIF.BLDG AN ❑YES RECEIVEDBY: TOT 1. LUATION: PLANNINGAPPLM� PLANNING APPROVAL LETTER k:ICiILER 110,l:! �NO A�/`V By my signature below,l certify to each of the following: I am the property owner or authorized agent to act on the prOperty ow'ner's behal l: I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply With all applicable local ordinances and state haws relating to b Rding eonstruction. 1 authorize representatives of Cupertino to enter the above-id nnEd ropem for inspection purposes. Signature o(Applicani/AgenC a Date: � -�y /.� SUPPLEMENTAL INFORMATION REQUIRED PLASCBECK TYPE 1�,, ROUTING SLIP New SPD or Multifamily dwellings: Apply for demolition permit for OVER-TRh:CO11,NTER lEl BUILDING PLAN NEVIEw existing building(s). Demolition permit is mquired prior to issuance of building / / permit for new building. ElEXPRESS ❑ PLANNING PIAN REVIEW _Commercial Bldgs: Provide a Completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUHI.IC w'oRKS form if any Hazardous Materials are being used as pan of this project. ' ❑ IARGF; ❑ FIRE Uf:PI' _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR El SANITARY SEWER DI51'RICT submittal of Building Permit application. ❑ ENVIRONMENTA L HF.ALTII BlelgApp_201 l.doc.revised 06121/11