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15110072CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10201, PHAR LAP DR CONTRACTOR:' ° " i PERMIT NO: 15110072 OWNER'S NAME. MA ROBERT K AND TINA M DATE ISSUED: 11/1212015 OWNER'S PHONE ", PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL al_ DEMO (E) FAMILY ROOM (432 SF) License Class i Lic. # g Contractors rA� of r ' Date I hereby affirm -that I am licensed under the provisions of Chapter 9 (commencing with Seetion,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 I have and?will inr .tain a certificate of consent to self - insure for Worker's Compensation; as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $10000 '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 Lahot Code; 'for the performance of the work for which this permit is issued. " � APN Number 32639052.00 Occupancy Type: APPLICANT CERTIFICATION 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 ientioned 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 -point source regulations per the Cupertino Municipal Code, Section 918. fr Signature Ae ;�V y � A Date., RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without fast obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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) I, as owner bf the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec,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, Sectrons,550, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: s ,. ; Date..) d1 Z permit is issued. , 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 LENDING AGENCY become subiect,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 (See. 3097, Civ C.) �+ 3 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 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 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building Acupertino.org PROJECT ADDRESS _FAPN / 0; 'DI_ c,l I # �Ib q Is — () OWNERNAME PHONE 1/d .7 !17 te)- E-MAIL STREET ADDRESS I; CITY, STATE, ZIR FAX CONTACT NAMEi ErIL STREET AD 1 -1 or CITY, STATYIP 4 FAX Yoe ❑ OWNER ❑ OWNER - BUILDER 1:1 OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRAFOR0 NA E q Aw LICENSE NUMBFIR LICVE TYPE BUS. LIC Zbe- kki _".'r 4 Ae 94 COMPANY NAME, E-MAIL FAX STREET ADDRESS IV ee CITY, STATE, Z)P �FH w re 141"% t DESCRIPTION OF WORK ` 4" 1 45, 16 SE) RESIDENTIAL # DWELLING OFFICE USE ONLY FLOOR AREA UNITS USE OCC, TYPE SO,Fr. -,VALUATION COMMERCIAL FLOOR AREA TYPE OF CONSTRUCTION 4 STORIES AQMD JOB NUMBER T RECEIVEDBY: TOTAL VALUATION: #: ZA AC-MAI /L),D(2C2 By my signature below, I certify to each of the following: I am the property owner or authorized age lit to act on the p rty 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 accuratdagree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature ofApplicant/Agent: Date: SUPPLEMEN`rAL INFORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT OFFICE USE ONLY PLAN CHECK TYPE Provide Job Number from Bay Area Air Quality Management District AEAjgqqmAm @ 415-749-4762. ❑ EXPRESS'. Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above grade, Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected. STANDARD Provide a letter of inspection, tests, and abatement of any Hazardous Materials. Letter to be initiated by person(s) LARGE certified in asbestos, mercury and/or hazardous material examination, ❑ MAJOR Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days. Provide letter of clearance of all vermin from a licensed pest control contractor. Applicant shall call the Public Works Department at 408 -777 -3104 and schedule a "habitable dwelling' inspection. --- Provide signed Debris Bin and Recyclable Materials form. Commercial Buildings Only: Provide Fire Dept clearance for fire suppression / alarm system review. DenroApp_201 ].doe revised 03116111 AWe k� MN RmS. N 'N , , " """"'0" - N. NIP 'P Ml 7— F1, 1 � Z, T Ele6, f e ,?Tfie 1"'T" hqp. L1 AU UM I his estimate does not include fees due to other Departments (i. a Planning, Public Works, Fire, Sanitary Sewer District, School District ote-). Thevfoovnro hawdon the nroliminary infarmation avaiinhipa"darpinthy an ovtimatp Cn"tiyrf tho Dont fy)r"Al"11 !"fn FEE ITEMS (Fee .Resolution 1.1-053EV 71'1113) FEE ID FLR AREA Ls. f.) MISC ITEMS P( 17ee 1DEMORES 432 Permit Fee: $574.00 Suppl. Insp. Feeig Reg. 0 OT:==hrs $0.00 xWoh .Admhli,wr� aire If e TV6�k ff"ilhout Permill" ONE. 1751M MN RmS. N 'N , , " """"'0" - N. NIP 'P Ml 7— F1, 1 � Z, T Ele6, f e ,?Tfie 1"'T" hqp. L1 AU UM I his estimate does not include fees due to other Departments (i. a Planning, Public Works, Fire, Sanitary Sewer District, School District ote-). Thevfoovnro hawdon the nroliminary infarmation avaiinhipa"darpinthy an ovtimatp Cn"tiyrf tho Dont fy)r"Al"11 !"fn FEE ITEMS (Fee .Resolution 1.1-053EV 71'1113) FEE QTY /FEE MISC ITEMS P( 17ee Permit Fee: $574.00 Suppl. Insp. Feeig Reg. 0 OT:==hrs $0.00 xWoh .Admhli,wr� aire If e TV6�k ff"ilhout Permill" TF,amol Strong Motion Fee: IBSEISMICR $1.30 Select an Administrative Item Bldf-, Stds Commission Fee: JBCBSC $1.00 -11 11-111-1- EIR !"M —111 mx, 111 1,11 1 AN, -XV2 $576.30 $0.00 $576.301 Revised: 10/01/2015