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09080003 - PUB=ile Edit Actions Details Links Favorites Help L III 4* X Uh a Permit Inforration Location Information Permit Number' ,09080003 ti Address 1144 DERBYSHIRE DR — ---- - Status ' v City/State/Zip CUPERTINO CA L95014 Master Number Notes 0. APN (36221026.00 Project CQ� Unit Apply Date ` 08/03/2009 Operator rpatg 01,vner Entity Pnformation Permit Issue Date 08/03/2009 __ .. Operator patg f Owner Name' ANWAR AWAD Certificate Issued 10/05/2009 — Operator PALM Use Default Certificate Type - - - - - Address Home -1144 DERBYSHIRE DR v Certificate Number - - City/State/Zip CUPERTINO CA C '95014.507-27 Permit' 1 PY� ty Zoning I Applicant 11 Contractor' !� Defined Fields Permit Details - Permit Type 1R3SFDREM o' SINGLE FAMILY DWELLING REMODEL Usage Class' 11/111 B, U' II/III B, IV -HT V-B NEW Applied Value " �— 800 SQUARE FT. , Calculated Value 0 01 US C-404 Type 434 'A1 LT: RESIDENTIAL Permit Form" AUTOPERM -PERMIT Ownership 1 -Private v Project Size LCOUNTER - OVER THE COUNTER v 'ermit issued 08,f03 f 2009 Inter permit status Purpose/Special Conditions - — (STRUCTURAL CHANGE TO MOVE A SACK DOOR LEADER IN TH CEILING; NO RE-RF, HOWEVER, DOES HAVE STRUCTURAL I(]Add Default T w 3 %/ 0 K Back lC�i Contractors w , Fees j Plan Reviews F' I nspections l qj Print Permit Adjustments Holds l00 Copy Permit �q Close Permit Overrides Supplemental Fields Notes �� Attachments J CITY OF CUPERTINO BUILDING PERMIT. BUILDING ADDRESS: 1144 DERBYSHIRE DR CONTRACTOR: TBD - TO BE DETERMINED PERMIT NO: 09080003 OWNER'S NAME: ANWAR AWAD DATE ISSUED: 08/03/2009 OWNER'S PHONE: 6508611354 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r— r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # r r MECH RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: STRUCTURAL CHANGE TO MOVE A BACK (commencing with Section 7000) of Division 3 of the Business & Professions DOOR LEADER IN Code and that my license is in full force and effect. THE CEILING; NO RE-RF, HOWEVER, DOES HAVE STRUCTURAL 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: $800 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION APN Number: 36221026.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date Issued by: Date: L�1 OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: Date: 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 declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the 1 have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should I store or handle hazardous material. permit is issued. Additionally, should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued, I shall 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 not employ any person in any manner so as to become subject to the Worker's health & Safety Code, Sections 25505, 25533, and 25534. 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 Owner or authori ed agen forthwith comply with such provisions or this permit shall be deemed revoked. Date:-- 0 IF I APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. 1 agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address 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 ARCHITECT'S DECLARATION 9.18. D SignatureDate I understand my plans shall be used as public records. Licensed Professional o90P o003 CITY OF CUPEkTINO CITY OF CUPERTINO ADDITION/REMODEL PERMIT APPLICATION FORM APN # 2 / /D D 0 Date: Is a 2" unit being added? Yes ❑ No elf yes, please fill out the permit application for 2" unit. Building Address: r��r ��,�� C A of Mailing Address (if different from building addr ss): Owner's Name: A � �.r .aid► Phone # 3 Contractor: T ED Phone #: Fax #: Contractor License #: Cupertino Business License #: Contact: A Y� WQIt n Phone #: N Fax #: Building Perms Info: Bldg. Elect. ❑ Plumb. ❑ Mech. ❑ Hillside ❑ Job Description: Addition -What is being added?(Be Specific): ajA j-4 ,n . �j'rc �. a,--rc, I ck' I 0 hove a 'PC cerl� What is being remodeled (not including addition)? Remodel Includes Re -Roof. Yes ❑ No [ If yes list number of squares Remodel Includes Structural: Yes No ❑ Do you have the pre -application planning approval? Yes ❑ No E If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other - Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B [' II/III/V-A ❑ II/III B, IV -HT, V-B P__�7 Valuation: 9d� Please check this box if the project is a Size: Express 2/standard❑ Large ❑ Major ❑ second -story addition ElProject 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 CUPEI�TINO CITY OF CUPERTINO ADDITION/REMODEL FEE SCHEDULE Quantity Sq Ft Fee ID Fee Description Fee Group Permit Type ADDITIONS 1R3SFDADD 1 PLLONGRNGR Long Range Planning/Residential PL 1 R31NSP Dwellings Inspections B 1 R3PLNCK Dwellings plan check B 1R3REPINSP Dwellings Repeat Inspection B 1 R3REPPLNC Dwellings Repeat Plan Check B 1R3HINSP Dwellings Hillside inspection B 1 R3HPLNCK Dwellings Hillside plan check B 1R3HREINSP Dwellings Hillside Repeat Inspection B 1 R3HREPLNC Dwellings Hillside Repeat Plan Check B 1 R3ALTINSP Dwellings Alternate Materials Inspection B 1 R3ALTPLNC Dwellings Alternate Materials Plan Check B 1PCESS Cesspool P 1 PPRSEWG Ea. Private Sewage Dis osal System P 1 PRSEWER Sewers P 1BPSPRINK Lawn Sprinkler/Backflow P 1BPWSVCS Main Water Service P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICRE SeismicResidential B 1RER00FRES Residential Re -roof Each 100 SF B Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 6V OF Fax (408) 777-3333 CUPEkTINO Building Department JOB ADDRESS: PERMIT # CIA °1S—ol'I OWNER'S NAME: PHONE # 6 s—D 1 ( 13 S- GENERAL CONTRACTOR 'c 2c1 FAX # I am not using any subcontractors: Signature Please check arn)licable subcontractors and complete the following information: 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