13040148 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 882 BROOKGROVE LN CONTRACTOR:T-BP T^vE PERMIT NO:13040148
DT.XERMWED
OWNER'S NAME:.ZASLOW JANETTE n
I a0( DATE ISSUED:04/19/2013
OWNER'S PHONE: 4088139169 �e�i G PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL[]
License Class �L—1 n Lic.# 7-22156 PANEL UPGRADE 200 AMP-EICHLER HOME
Contractor (i, o r ff)eC.f r L bate y_ 9 13
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:$2700
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:37539041.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that.1 have read this application and state that the above information is PERMIT E IBES IF WORK IS NOT STARTED
correct:I agree to comply with all city and county ordinances and state laws relating WITHIN D YS 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 DAY LAST CALLED INSPEC ION.
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-point source regulations per the Cupertino Municipal Code,Section
9.18.
�? RE-ROOFS:
Signature 4AYDate f 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-BUILDER`DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not interided or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(See.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(a)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 with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor.Code,for the performance of'the work for which this
permit is issued. Owner or authorized agent: Date:
I certify that in the performance of thework,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 law California. If aftefmaking this certificate of exemption,I CONSTRUCTION LENDING AGENCY
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.1 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
I I
illi I I,,I I I I '
,I
I
I
GENERAL PERMIT APPLICATION
M
EP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION v
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)1777-3228•FAX(408)777-3333•buildingCa)cupertino.org m1sc
CWPRRT1N0 A�
` PLUMBING MECHANICAL LECTRICAL ❑MISCELLANEOUS
��Ieojlcl
ADDRESS „ APx#
OWNERNAME tt PHO uOg� O 13^ 4 1 g E-MAIL
STREET ADDRESS CITY STATE,ZIP FAX
I� Z l''3c�bot�C t"c�vC..— �u +t�..c7 C/4-"
CONTACT NAME 11I ', � PHONE E-MAIL
I,
STREET ADDRESS, CITY,STATE,ZIP FAX
I
W;NER ❑ OWNER-BUILDER ❑.OWNERAGENT'. ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR N,AM$�/�,/ ,. ? LICENSE NUMBER -7 s 1 r,r LICENSE TYPE O BUS.LIC#
E-MAIL D JO FAX
COMPANY NAM l :i' c✓ec,+f ( —
ST I CITY,STTE,ZIP JT q PHONE
K t7SC_
ARCiCTGER NAME `I j LICENSE NUMBER BUS.LIC#
I I 'p1j11
') EMAIL FAX
COMPANY xAMP I I
1 I I
STREET ADDRESSCITY,STATE,ZIP PHONE
I.
USB I OF 8FD or DUPLEX ;� MULTI-FAMH.Y PROJECT IN WB,DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN YES
BUII.DING I�; ❑COMMERCW. ! URBAN INTERFACE.AREA NO FLOOD ZONE ❑NO EICHLERHOME? ❑ O
DESCRIPTION OF,*ORIS ".I
11 , III '
1 �II 1
:II .
1
I I
�III IC I I�I I I di,lj I
TJ .I
I.
ALA PN M per'
I
I
O� L�A .
appli atro�n and'{ilpe Informal on I haevaecp of the following: I am the property owner or authorized agent to act on pr rty owner's behalf. I have read this
B sI aturg 1o�N; ' '
ovider is correct. I have read the Description of Work and verify it is accura . I agree to comply with altapphcable locale
ordln'ances andstate lbws relakingto}budding construction. I authorize r tatives of Cupertino to enter the a/bo/ve-Identified property for inspection purposes: :
Signature¢f ApplicairtiAgent:�y,� Date: `Z —�/ '-�
i 1.,, I I '' I ',SUPPLEMENTAL INFORMATION REQUIRED
II I tlll�l 'SII I I I� II: ISI Ilii 'lil I , ! I I
li III �I�; �Illil I I !I IIII II ,II�I 'lll I
I I I i{i u ' I II
I
I IIII I I I II 1 ,
MEPMiscApp_2011.doc revised 06/21/11
lSII"II ��111 I �I � I
ig II II,I I I I I
II !I IIII , IIS I I I, II
I
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 888 BROOKGROVE LN DATE: 04/19/2013 REVIEWED BY: MENDEZ
APN: —TB—P#: "VALUATION: J$2,700
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION 1 REAP2
USE: SFD or Duplex PERMIT TYPE:
WORK PANEL UPGRADE 200 AMP-EICHLER HOME
SCOPE
ry .
m
leclz,Plan Ch<:ck' Pharrb.Plan Check Elec.Plan Check 0.0 hrs -,$0.00
41ech.1'ernrit Fez:. Plumb.Permit Pee: Elec.Permit Fee: IEPERMIT
Ot/res•h9ech.Insp. Other Plumb Insp. Other Elec.Insp. 0.0 hrs $45.00
Mech.Insp. Fee: Plumb. Insp.Fee: Elec.Insp.lee
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimin information available and are only an estimate. Contact the Dept for addn'l info,
FEE ITEMS(Fee Resolution 11-053 E . 7ff 11?) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F200amps Electrical
Suppl.PC Fee: Reg. .Q OT 0.0 hrs $0.00 $45.00 IBELEC200 Services
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:Q Reg. Q OT 0,0 hrs $0.00
PME Unit Fee:. $0.00
PME Permit Fee: $45.00
Construction lax.
Administrative Fee: 1ADMIN $42.00 0
Work Without Permit? Yes iq No $0.00
Advanced Planning Fee:: $0.00 Select a Non-Residential E)
Building or Structure: .®
Travel Documentation Fee::. 1TRAVDOC $45.00 i .
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee:_ 1BCBSC $1.00
$133.50 $45.00 $178.50
Revised: 04/01/2013
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.# Un
OWNER'S NAME: 1S 0 ic.. i s` PHONE# Ll02 t'/:/1, 66 IS
GENERAL CONTRACTOR: ,,,,.bwch "')ec �L 1/��, BUSINESS LICENSE#, . -i o 7%"L156
ADDRESS: e{ 7 crnze,., ,4vc_ `SOS4 C,� CITY/ZIPCODE:Sc.� a 4A �St2Y
*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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. --- y
I am not using any subcontractors: -
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
y4 ,
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date