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CITY OF CUPERTINO•BUILDING PERMIT
BUILDING ADDRESS: 10630 STOKES AVE CONTRACTOR:JON ANDERSON BUILDS PERMIT NO: 10040129
OWNER'S NAME: BOB&JULIE GOODMAN PO BOX 320094 DATE ISSUED:04/27/2010
OWNER'S PHONE: 4087251948 LOS GATOS,CA 95032 PHONE NO:(408)761-2098
❑ LICENSED CONTRACTOR'S DECLARATION r F- F_
BUILDING PERMIT INFO: BLDG ELECT PLUMB
A 04 License Class .3 Lie. r
MECH RESIDENTIAL COMMERCIAL
Contractor t� t7�rt �ty( ate 16
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE WALL/REPLACE WITH BEAM,UPDATE
(commencing with Section 7000)of Division 3 of the Business&Professions KITCHEN;
Code and that my license is in full force and effect. REPLACE SLIDING DOOR-INDLUDES STRUCTURAL(300'),
NO RE-ROOF
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.
[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. Sq.Ft Floor Area: Valuation:$60000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:32649005.00 Occupancy Type:
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additio lly,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-poin source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature _ Date [ C �Q Issued by Date:
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
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,1 shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain com liance wit the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Sa ety Code,, ctions 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
i
Owner,o lltl>stx I%d.. a 1D
forthwith comply with such provisions or this permit shall be deemed revoked. `.._ Date: /
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 1 hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which y accrue against said City in consequence of the Lender's Address
granting ofthis pe it.Ad tionally,the applicant understands and will.comply
with all non-po4nlouo�iigulabons per the Cupertino Municipal Code,Section
9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date Q
J Licensed Professional
v
t
CITY OF CUPERTINO
ADDITION/REMODEL
OF
CUPERTINO PERMIT APPLICATION FORM
APN# , f Date: t1
17-r-I/
Is a 2"d unit being added? Yes ❑ No ❑ If yes, please fill out the permit application for 2" unit.
Building Address:
10(050
Maili Address (if different from building address): _
Owner's Name: Phone#
Coo _V �q,z�
Contrr�tor: Phone#: 903 —7(0
AkolOFax #: 390— AR SS__
Contractor License#: F�
Cupertino Business License#:
Contact: Phone#:
�_360!!�tj A,,j Fax #: 5
Building Permit Info:
Bldg. P_' Elect. Plumb. Mech. [� Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
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 ❑
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 11/III/V-A ❑ 11/111 B, IV-HT, V-B �7
Valuation: 6� &Nu �� /G Please check this box if the project is a� second-story addition ❑
Project Size: Express Standard y Large ❑ Major ❑
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
6
t
-~� CITY OF CJPERTINO D
ADDITION/REMODEL
CITY OF
CUPERTINO FEESCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
ADDITIONS 1R3SFDADD
1PLLONGRNGR Long Range PL
Planning/Residential
1 R3INSP Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Ins ection
1R3REPPLNC Dwellings Repeat Plan B
Check
1R3HINSP Dwellings Hillside B
inspection
1R3HPLTICK Dwellings Hillside plan B
check
1R3HREINSP Dwellings Hillside B
Repeat Inspection
1R3HREPLNC Dwellings Hillside B
Repeat Plan Check
1 R3ALTINSP Dwellings Alternate B
Materials Inspection
1R3ALT•PLNC Dwellings Alternate B
Materials Plan Check
1PCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
Disposal System
1 PRSEWER Sewers P
1BPSPRINK Lawn Sprinkler/Backflow P
1BPWSVCS Main Water Service a P
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE SeismicResidential B
1RER00FRES Residential Re-roof Each B
100 SF
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: /N3t7 PERMIT#'1006
OWNER'S NAME: 6 PHONE# S�1
GENERAL CONTRACTOR: BUSINESS LICENSE# PZ dv^�
ADDRESS: CITY/ZIPCODE:
*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.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V 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
�f 27 b
%' OwContractor Signature Date