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12110149CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1105SCOTLANDDR COINTRACI'O1t:+M3,- i6i31i I'ERDII'I' \0:12110149 AFF£RMfNED O\1'NER'SNApIE: MONTANEZ JOSEPH I AND KATI'IERIN DATE ISSl1ED: 11282012 O\N'NER'S PHONE: I , I PHONE NO: ❑. LICENSED CONTRACT'OR'S DECLARATION License Class G"3b—L'1.ic.N �13�t1�1 Contractor UL Date it 2 (� 1 hereby affirm that I am licensed under the precisions of Chapter 9 (commencing with Section 7000) of Dhision 3 of the Iusiness & Professions Code and flint my license is in full force and effect. hereby affirm under penalty of perjury one of the following mo 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. APPI- IC, \N'1' CER'rH'IC,\T1ON I certify that 1 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 constriction, 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, costs, and expenseh`ch may accrue against said Citc in consequence of the graining of a it. Additionall}•, the applicrmt understands ad will comply with all -poih uce regulations per the Cupertino Municipal Code, Section 9.18. Signs ire 'Date ❑ OWNER-BUILDER DECI - %RATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 constrict the project(Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 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. 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 become 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. APPLIC\\ T CERTIFICATION 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 mid 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 3011 DF.SCRII''1'ION: RESIDEXHAL PROPERTY LINE CLEAN OUT Sq. FI Floor Area: Valuation: $2601 ANN Number: 36226037.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN DAYS OF PERMIT ISSUANCE OR 180 UAY OM LAST CALLED INSPECTION. Issued by: L Date: ll / 0, RE- ROOFS: All roofs shall be inspected prior many roofing material being installed If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BF-TIT;R' IIAZARDOIJS MATE.RLVS DISCLOSURE have read the hazardous materials requirements under Chapter 6.95 of the California lleallh & Safety Code. Sections 5505. 45533. and 25534. 1 will maintain compliance with the Cupertino Muniei pal Code. Chapter 9.12 and the Health & Safety Code. Section 25532(x) should I store or handle hazardous material. Additionalh', should I use equipment or devices which emit hazardous air contaminants as define i • the Bar, \rca Air Quality Mamtgemenl District 1 will maintain co ild a a w'ilh Cupertino Municipal Code. Chapter 9.12 and the Health & Safety .ode. Secii n : _ 505. 25533, and 25534. Owner or authorized ate: 1l CONSTRUCTION I,FNDINGAGFNC1' I hereby of inn That there is a constmction lending agency for the performance of stork's for which this permit is issued (Sec. 3097, Civ C.) Leader's Name Lender's Address ARCIIITECI "S DECLARATION I understand my plans shall be used as public records. Licensed - CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408-777-3228 Pax: 408-777-3333 JOB ADDRESS: -1kD5 tL PERMIT# OWNER'S NAME: PHONE # 610) LS'1 GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: UV5% . nJJsk CITY /ZIPCODE: F=14•✓wA (M- k4t5n *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUIRINICY INSPECTION(S) WILL BE, SCHEDULED UNTIL THE GENERAL CONTRACTOR AND A SUB NTRACTORS HAVE OBTAINED A 797 TINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS- LICENSE # Cabinets & Millwork ; Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing �p%1 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date F�� CITY OF CUPERTINO "IN FEE ESTIMATOR — BUILDING DIVISION JAFADDRESS: Plumb. Plan Check 0.0 1 hrs $0.00 DATE: REVIEWED BY: BP FEES APN: BP#: 'VALUATION: $2,601 *PERMIT TYPE: Plumbing Permit # PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Permit Fee: PENTAMATION 1 RPSS PERMIT TYPE: WORK SCOPE PME Unit Fee: APPLIANCE /EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES Elec. Pernuit Fee: Sewer, Sanitary 1PRSEWER Other rice. lwp. El 1 # $23 Permit Fee: Suppl. Insp Fee PME Unit Fee: $23.00 PME Permit Fee: $45.00 Consotiction Tnv: Administrative Fee: 1ADMIN $42.00 Work Without Permit? O Yes Q No $0.00 TOTALS: i Travel Documentation Fee: ITRAFDOC $23.00 Strong Motion Fee: 1BSEISMICR NOTE: This estimate does not inclurdejeer due to otter Departments (i.e. Planning, Public Works, Fire, Sanitary Server District, School District, etc.). These feav are baser/ on the prelitninari information arailable and are only an estimate. Contact the Delujor atddn'I info. FEE ITEMS (Fee Resohnion 11 -053 E(! 7111122 Much. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 Flee. Plan Check blech. Permit Fee: Plumb. Permit Fee: I PPERMIT Elec. Pernuit Fee: Other Afech. lay. Other Plumb Insp. 0.0 hrs $45.00 Other rice. lwp. El .tfech. bap. Fee: Plumb. bt.p. Fee: F.lcc. Insp. Fee: NOTE: This estimate does not inclurdejeer due to otter Departments (i.e. Planning, Public Works, Fire, Sanitary Server District, School District, etc.). These feav are baser/ on the prelitninari information arailable and are only an estimate. Contact the Delujor atddn'I info. FEE ITEMS (Fee Resohnion 11 -053 E(! 7111122 FEE QTY /FEE, MISC ITEMS Plan Check Fee: st,ppl. PC /,-("e PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee PME Unit Fee: $23.00 PME Permit Fee: $45.00 Consotiction Tnv: Administrative Fee: 1ADMIN $42.00 Work Without Permit? O Yes Q No $0.00 Advemecd Planning Fees; i Travel Documentation Fee: ITRAFDOC $45.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $156.50 $0.001 TOTAL FEE: $156.50 Revised: 1 0101 /201 2 c� -7 5,50 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(aCUDeriino.ora ?L --' BMDJG ❑),,MCrIA -MCAL a� MEN' v\ MISC ❑=LEC7 ckL ❑masc .I?.NEOUS PR0=A- DDRESS F 10 5 ! �.`.�+r - 0-- I /„ `1 (MAM kvvcz_ OWNER NAME Q —>ZD(5 vV1CD�1 i��\C3Z- PHON= I o\cl 4o1 -(0005 c- ' s T x=� I.DnRESSx `OS SC�'iTC_IV'>�, V') DQ L t1 l,Tl4.l� �i , Soli 1 •!x COT` TACT NAME (-1 ^ \` V f{o1r1 6�i�- Gttouo S �D �+ 1, I m n c �1a aus�;?i FAX ❑ ow'-R OWN-z -9=M ❑ ON'HER AGcT"i CONTRACTOR ❑CANiRA=RAGar ❑ ❑ DEV=APzt ❑ 7rAN7 COI-.iAA ANAME ul YSa�2l� L C- ..''�'S =N1 I \\1tn� U - iSETYFE C G'4� I BUS. UC: �I NAME 'PlfrysPoMSv LhYGJ.%P _� MC' I _ NM FAX SCR_— iADDRESS Llv,\ .Y. -11.1 C.�.... Mti- 10� F'��"', STAT; 21? �''Lw� a t� r mow' ti'�'��`'✓ y PHOh= �wJ 25'l- t 3.� - AR0--vM- CMENGIN"EZ NAME LICENSEE NUNSut I BUS. LCB COMPANY NAME' I 'E-M-11L FAX STRc1' ADD FMS CIY. STA -ZIP I PHONE USE OF ❑ SM s DUPLEX ❑ MULTLFANIE.Y 9=TNG: ❑LOMMERCTAL PROSECT IN WD.DL.kN'D ❑ YES I URBAN INTERFACE AREA ❑ NO FROTH IN ❑ Y3 FLDOD ZONE ❑ NO is TFM BLDG AN ❑ Y-- EICHLER HOME7 ❑ NO DESC 014 OF woA ' yllw (�tsa�Ui r1v�7 ��uJ'o��`q Lt�n� i>4I TOTALVALUATION: pA(OOl RECEiV =D BY: By my signan:re below, I c_ -rtify to each of the fallowing: I= the pmpery owner or ztmSonzcd agent to act on the property owner's behai ". havc read this applicz:ion and the informaD a _p 5 CO=CL I have read the Description of Woa: and vcrify it is aecnrzte. I ag-te p comply with Ell applicable local ordinznces and stare laws ating . ding co srs ' . L orize rep,., eatativet o`Cnperino to enter :he ab`v� ii gq3 p ,y for inspccdon put oscs. Sig: aam:0fApalicznUA. •nn Da_: Illl L SL-PPLEN - NI'AL, iNrORMATION REQUIRED OFEICS USE ONLY O u G 0 i OVER- THE {ODNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ NwOR ?,j:-:'?h.uc?pp_?011.doc revised 06121111