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11090018 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10817 W ESTATES DR CONTRACTOR:.JM`CONSTRUCTION PERMIT NO: 11090018 OWNER'S NAME: ELIZABETH MULLEN 562 DIVISION ST DATE ISSUED:09/02/2011 OWNER'S PHONE: CAMPBELL,CA 95008 PHONE NO:(408)379-9852 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALE] License Class Lic.# w MINOR ROOF REPAIR,REPLACE EXTERIOR DOOR AT - 7 �{�j Q 5 I GARAGE Contractor( �,n �� y u&A-'!A Date a t I LOCATION,SERVICE PANEL UPGRADE I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I 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. Sq.Ft Floor Area: Valuation:$4800 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:36923035.00 Occupancy Type: permit is issued. +6 APPLICANT CERTIFICATION c I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county 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 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-poi Ip ource regulations-Rer the Cupertino Municipal Code,Section 9.18. ( RE-ROOFS: SignatureJ, Date_11 l << All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUIldDER DE LARATION Signature of Applicant: Date: t Hereby affirm that I am exempt the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,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) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Scc.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I 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&Safety Code,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure 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 with2n57 pertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec533 nd 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: permit is issued. l 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 CONSTRUCTION LELGAGENCY 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. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION 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 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, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. ting of this permit.Additionally,the applicant understands and will comply i all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 18. t 0 14gnature Date CITY OF CUPERTINO 6 ITEMS OF 10 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 36923035 . 00 DATE ISSUED. . . . . . . : 09/02/2011 RECEIPT #. . . . . . . . . : BS000014664 REFERENCE ID # . . . : 11090018 SITE ADDRESS 10817 W ESTATES DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ELIZABETH MULLEN ADDRESS 10817 W ESTATES DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4537 RECEIVED FROM . . . . : JM CONSTRUCTION CONTRACTOR EDENS, JIM LIC # 20955 COMPANY JM CONSTRUCTION ADDRESS . . . . . . . . . . : 562 DIVISION ST CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 379-9852 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 800 . 00 1 . 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 4, 800 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0. 00 1ERT<200 UNITS 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1WINREP EACH 8 1 . 00 392 . 00 0 . 00 392 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 525 .50 0 . 00 525 .50 0. 00 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 10827 w.estates dr. DATE: 09/02/2011 REVIEWED BY: bobs. APN: BP#: W VALUATION: $3,500 "PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair USEMARY SFD or Duplex PENTAMATION PERMIT TYPE: 1 GENRES WORK sfd minor roof repair, replace exterior door at garage location sercice Danel upgrade. SCOPE Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: 1EPERMIT Other Elec.Insp. 0.0 hrs $44.00 NOTE. Thesefees are based on the preliminary in ormadon available and are only an estimate. Contact the Dept for addn 7 info, FEE ITEMS (hire Resalutior7 11-0531) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 E 11 # Window/Sliding Glass Door Suppl. PC Fee: G Reg. 0 OT 0.0 hrs $0.00 $392.00 1WINREP Replacement PME Plan Check: $0.00 200 amps Electrical Permit Fee: $0.00 $44.00 IERT<200 Services Suppl. Insp. Fee.e Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 Acoustical Fee: 0 Yes E) No $0.00 0 Work Without Permit? Q Yes 0 No $0.00 Planning Fee: $0.00 Select a Non-Residential E) Travel Documentation Fee: 1TRa vDOC $44.00 Building or Structure i Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee' 1BCBSC $1.00 SUBTOTALS: $89.50 $436.00 TOTAL FEE: $525.50 Revised: 07/04/2011 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 -[1- CUPERTINO (408)777-3228• FAX(408)777-3333• building(d)cupertino.org ' citol ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN# �I � 3 OWNER NAME s M PHONE E-MAIL STREET ADDRESS , W S S 4 r CITY, STATE ZIP0 FAX CONTACT NAME l PH E E-MAIL S4 V''�-P C%. STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# J 4. 7 COMPANY NAME n Y J _y Q E-MAILI L y L Q�S� O FAX sy-71 C� STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK l EXISTING USE PROPOSED USE CONSTR: PE STORIES 14 USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA pc BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ATTACH #DWELLING UNITS: IS A SECOND UNIT []YES YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prraperty owner's behalf. I have read this application and the information I have pr ided is correct. I h read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bui g consTnx— orize representatives of Cupertino to enter the above(-identified property for inspection purposes. Signature of Applicant/Agent: Date: { of SUPPLEME ORMATI Q D PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for dem ' ' n permit for ❑ OYER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR El SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 1.doc revised 06/21/11