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11080115 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21891 HERMOSA AVE CONTRACTOR:FIVE STAR WINDOWS PERMIT NO: 11080115 OWNER'S NAME: STEPHEN LIU 1450 DELL AVE STE C DATE ISSUED:08/15/2011 i NER'S PHONE: 4082525217 CAMPBELL,CA 95008 PHONE NO:(408)370-3331 Li LICENSED CONTRACTOR'S DECLARATION r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class 3— .� Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE 8 WINDOWS NON-STRUCTURAL FOR EXISTING (commencing with Section 7000)of Division 3 of the Business&Professions SINGLE FAMILY DWELLING Code and that my license is in full force and effect. 6 1 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 Sq.Ft Floor Area: Valuation:$7200 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35716074.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regi ilations per the Cope mo Municipal Code,Section 9.18. Issued by: �`� Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's r Compensation laws of California. If,after making this certificate of exemption,I er or an ror* ed agen become subject to the Worker's Compensation provisions of the Labor Code,I must ,� Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ag of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35716074 . 00 DATE ISSUED. . . . . . . : 08/15/2011 RECEIPT #. . . . . . . . . : BS000014444 REFERENCE ID # . . . : 11080115 SITE ADDRESS . . . . . : 21891 HERMOSA AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER STEPHEN LIU ADDRESS 21891 HERMOSA AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2801 RECEIVED FROM . . . . : FIVE STAR WINDOWS CONTRACTOR . . . . . . . : JEFFREY PICKARD LIC # 23690 COMPANY . . . . . . . . . . : FIVE STAR WINDOWS ADDRESS 1450 DELL AVE STE C CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 370-3331 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 7,200 .00 1. 00 0 . 00 1 .00 0. 00 1BSEISMICR VALUATION 7, 200 . 00 0 .72 0. 00 0 .72 0. 00 1WINREP EACH 8 8 . 00 392 . 00 0. 00 392 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 393 . 72 0 . 00 393 .72 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 393 . 72 #21455 --------------- TOTAL RECEIPT 393 .72 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21891 hermosa ave. DATE: 08/15/2011 REVIEWED BY: bob s. APN: BP#. "VALUATION: 1$7,200 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK re lace 8 windows non structural for exisiting sfd. SCOPE NOTE: Thesefees are based on the preliminaty information available and are only an estimate. Contact the De t or addh 7 info, FEE ITEMS (Fee Resolution 11-053 7,%1..!11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 ® # Window/Sliding Glass Door Suppl.PC Fee: 0 Reg. 0 OT0.0 hrs $0.00 $392.00 1wiNREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee-E) Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes E) No $0.00 0 Work Without Permit? 0 Yes E) No $0.00 Planning Fee: $0.00 Select a Non-Residential Building or Structure i Strong Motion Fee: IBSEISMICR $0.72 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $1.72 $392.00 TOTAL FEE: $393.72 Revised: 07/04/2011 / I (DR CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•building(a)cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION 9-ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN# � 0-� .Z % l/ OWNERNAME �\ {�/Y l PHONE E-MAIL STREET ADDRESS � CITY, STATE,ZIP-\ FAX CONTAC NAME PRONE TT E-MAIL ex-r%.C& STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER pp❑ OWNER AGENTQNTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTR CTO NAME ` \�,{@'�� LICENSE NUMBER ` LICENSE TYPE\ BUS.LIC# COMPANY NAME E-MAIL 3 FAX STREET ADDRESS1 � " � CITY,STATE,ZIP �,U/\ PHONE Ib10 ARCIIITECT/ENGINEER NAME LICENSE NUMBER � BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PIIONE DESCRIPTION OF WORK .. EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES OFFICE I I Dec. TYPE SOJZT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL 1 AREA AREA AREA NET AREA tf`r BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH ❑ ATTACH M DWELLING ON]I'S: IS A SECOND UNIT ❑YFS SECOND STORY ❑YES BEINGADDED? ❑NO ADDITION? ❑NO PRF.-APPLICATION ❑ YES IF YES,PROVIDE-COPY OF PLANNER'S NAME: RECEIVED BY: TOTAL VAL UAST ON: PLANNING APPL A ❑ NO PLANNING APPROVAL LETTER /3 �, • r Oc> By my signature below,I 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 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 laws relating ildi g construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent { Date: &� SUPPLEMENTAL FORMATIO R QUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for O�-T CdOUNTER BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. 0 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. 0 LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR 13 SANTTARY SEWER DISTRICT submittal of Building Permit application Q ENVIRONMENTAL HEALTH BldgApp_201 1.doc revised 03/16/11 Shining Above The Competition Family Owned and Operated Since 1983 1450 Dell Avenue, Suite C, Campbell, CA 95008 1 Tel 408-370-3331 Fax 408-370-3110 License# 628381 www.fivestarwindows.Com DATE: JOB NAME: S. ;'-T-\0 W f , SW �� APPR N1t1T be keit 3t ti^A 2nd sectficat'ons ,lawful to r it y !a "ion• � � et f s C,` v � �'hl�s o �Irn cens.ry d4- W a'1A dl,, t•�y��.art s. eU 1�,ic;� cr attE:ta N � �,, }•-� .� — �ycharc�e� t aPProvrt!from th N0S Ing r:f th.s PAZ",ar. ;�, '0401 o P �) be ne',d'o;,f:rr^it of �� ,,,�,..�..-•.�..-' RI �–' 7 of"ITIV ------------ � w i- Never Promising More Than We Can Deliver. Striving To Deliver More Than We Promise. Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: \ PERMIT# OWNER'S NAME: PHONE# 0- GENERAL CONTRACTOR \VQ S 2 25, BUSINESS LICENSE # ADDRESS: 14.1 4t,b �c C , . CITY/ZIPCODE: C ;3oo *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONT CTORS HAVE; OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. - I am not using any subcontractors: A.Z - � Signature Date Please check applicable subcontractors and complete the following information: 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date