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09120105I CITY OF CUPERTIPIO BUILDING PERMIT I I BUILDING ADDRESS: 10693 PINOLE CT I CONTRACTOR: DANCE BUILDERS I PERMIT NO: 09120105 1 OWNER'S NAME: IRVING & SARA ROSENBLUTH 4939 OCCIDENTAL RD .ER'S PHONE: 4089962283 SANTA ROSA, CA 95401 ❑ LICENSED CONTRACTOO�R'S DECLARATION License Clas b .Lic. # S(960 ZI Contractor _44 ` Date 1 2- 1 1 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. 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 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 1 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 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 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 ! 2_ � -07 ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I 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. 1 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, 1 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, 1 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. 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 ur-n the above mentioned property for inspection purposes. (We) agree to save nify and keep harmless the City of Cupertino against liabilities, judgments, ck. 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_ DATE ISSUED: 12/16/2009 PHONE NO: (707) 546-0802 BUILDING PERMIT INFO: BLDG f- ELECT f- PLUMB f- MECH I- RESIDENTIAL f- COMMERCIAL I - JOB DESCRIPTION: ADD NEW 4'X4' SKYLIGHT IN LIVING; STRUCTURAL, 2 RAFTERS CUT & FRAMED WITH 2X12 RAFTERS Sq. Ft Floor Area: I Valuation: $1500 APN Number: 36934016.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. OwiLer,ol suthorizec�.al�j t: J��, Date: 1 I (O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional S_.Q.0 CITY OF CUPEkTINO CITY OF CUPERTINO ADDITION/REMODEL PERMIT APPLICATION FORM APN # 3� 3 � 1 � � DO Date! Is a 2" unit being added? Yes ❑ No C3 If yes, please fill out the permit application for 2" unit. Building Address: (p Mailing Address (if different from building address',: Owner's Name: � �"� + Phone # YV cl cl(o — 2Z93 lav t" l�Se�e tC3 Contractor: Phone #: Dh`t-ic--j v l Fax #: Contractor License #: 5r (a C Z ( Cupertino Business License #: qr Contact, NrOclet Phone #: 7 0 7 Fax #: 'L?8 --S7o0Z) Building Permit Info: Bldg. rM Elect. ❑ Plumb. [] Mech. ❑ Hillside ❑ Job Description: t l Addition -What is being added?(Be Specific): (V%tj � X LlSLYu g 4 -�_ �,(V j K�5 [20wrA What is being remodeled (not including additior.)? Remodel Includes Re -Roof: Yes ❑ No [] If yes list number of squares Remodel Includes Structural: Yes Et No [] Do you have the pre -application planning approval? Yes ❑ No ❑ If yes, please provide a copy of your plannin ; approval letter. Planners name: Square Footage: Addition: �_ Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: I -A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT,' -B [a--- V__3 Valuation: Please check this box if the project is a second-story addition ❑ Project Size: Express ❑ Standard ❑ Large ❑ Ma'or ❑ Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, Green Building Points Achieved: include in plan set & the sheet index. ***For Office Use Only*** Over -the -Counter ❑ Revised 07/06/09 CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Sq Ft Fee ID Fee Description Fee Group Permit Type 1 REMRES2 Remodel Residential Greater than 10(,0 sq ft B 1REMRES3 Remodel Residential Greater than 250 ) sq ft. B 1REROOFRES Residential Re -roof Each 100 SF B REMODEL PLNCK ISTPLNCK (1-3 for remodel) Standard Plan Check B NOT FOR OVER THE COUNTER PLAN CKS. WINDOW/SLIDING 1R3SFDREM GLASS DOOR 1 WINREP Replacement windows (ea 8 windows) B 1 WINNEWNSTR New Window (non- structural) B 1 WINMEWSTR New Window (S .ructural Shear Wall/Masc ) B 1 WINBAYSTR Bay Window (St:-uctural) B SKYLIGHTS 1R3SFDREM 1 SKYL<10 SF Skylight less than 10 sf B 1SKYL>10SF Skylight greater than 10 sf or structural B 1STAIRS Stairs -first flight/ ea addt'l B 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E CITY OF C.,UPERTINO ADDITOrI/REMODEL FEE SCHEDULE Quantity Sq Ft Fee ID Fee Descripilon Fee Group Permit Type 1MECPLNCK Stand Alone Mechanical Pln Ck (hourly M 1PLMPLNCK Stand Alone Plumbing Pln Ck (hourly) P 1BCBSC Cal Bldg Stancards Commission F, -,e B ALL PERMIT TYPES / 1BSEISMICRE Seismic Residf-ntial B 1TRAVD0C Travel & DocLmentation B 1BUSLIC Business License B S61ofe op �JOV-4 ��,�g � S:°�ya's lvviPer G'�C ZCYJ 7 �u (cQ.,� ��2 - KkZ 4�n -P f; ul 2X6 -Iss oR copk c�t 1N CV f'F RTIN() NUEI F� q'r�Tyf THE A DATE L. i�ANCES SIGNED - - - - This Set of Pept onlans nlawtu/ ►he fob at all MOST on same make anY chap mes and it is t e BuildingithOut wntten 9es or alteratio e stamPingDe�r rtn,ent Permission from s S At r NOT to .,I'sn ancf of Cupertino. aPProval th heli , I per specification t Of °f y m s in e "I,,r,;,,, R °r to an Y Cit - r j,. 'TT>roviStSt a;� .'l Z x RZ- z VA, �Z-C3' ;? 2- -s if L,L,) !4- LCI -1 LLIK 7- 4A-11� ��C) IL - CITY OF tXPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRE S: � 6 7 3 A,-8 4-e C�- 6-1pe-1-14A10 PERMIT # � a 0 OWNER'S NAME: PHONE # 7v Z .57 GENERAL CONTRACTOR: AX # 7 O 0 Z I am not using any subcontractors: Si;;nature Date 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 Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date