14100152l�'m
CITE' OF CUP ERTINO BUILDING PERMIT
BUILDING ADDRESS: 21 111 STEVENS CREEK BLVD
C�O`N�'T'RACTOR: 7 �
PERMIT NO: 14100152
( �[ -
77
OWNER'S NAME: CUPERTINO CITY OF
DATE ISSUED: 10/27/2014
OWNER'S PHONE: 4087773354
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
REPAIR (E) RETAINING WALL (194 LINEAR FT)
License Class Lic #
Contractor Date
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
Sq. Ft Floor Area:
Valuation: $188000
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
APN Number: 32629022.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
PERMIT EXPIRES PIR]Ci S ][][, WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS ®� ISSUANCE ®R
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 DAYS lFR � AL]LED 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
Date: ky
granting of this permit. Additionally, the applicant understands and will comply
Issued
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE- ROOFS:
Signature Date
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.
�,�s-
LE 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
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 (See.7044,
Business & Professions Code)
I, as owner of 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
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, 2553 and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner Date:
permit is issued.
or authorized agent:
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 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
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 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,
ARCHITECT'S DECLARATION
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 -poi t source regular per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date 0
U
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION
10300 TORRE AVENUE ^ CUPERTINO, CA 95014 -3255
(408) 777 -3228 ° FAX (408) 777 -3333 < buildinaacupertino.org
NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS ` �% � p ` I o
APN #
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OWNER NAME ® ` (� �
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11 OWNER 11 OWNER - BUILDER 0 OWNER AGENT 11 CONTRACTOR 11 CONTRACTOR AGENT 11 ARCHITECT C1 ENGINEER 11 DEVELOPER ❑ TENANT
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ARCIUTECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREETADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK o ®0, V1 As r&A'I 61 o a/ A
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
I
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECKIPORCH AREA
GARAGE AREA: UDETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY []YES
BEING ADDED? ❑NO
ADDITION? [J NO
PRE - APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECE B TAL V LUATION:
PLANNING APPL # []NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
O O 4D
By my signature below, I certify to each of the following: I am the property owner or authorized o the property owner's behalf. I have read this
application and the information I have provided is correct. 1 have read the Description of' Vork and ve1!5kfls accurate. I agree to comply with all applicable local
ordinances and state laws relating t uilding construction. I thorize representatives of Cupertino to enter the above - identified property for inspection purposes.
Signature of Applicant/Agent: Date: A1 Z
SUPPLEMENTAL INFORMATION R9QUIRED V
PLAN CHECK TYPE
ROUTING SLIP
1:1 OVER -THE•t OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
El STANDARD
El PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
El MAJOR
El SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addh7 info.
FEE ITEMS (Fee Resolution .11 -033 Eff %!1,x13)
ADDRESS: 21111 STEVENS CREEK BLVD DATE: 10/27/2014
REVIEWED BY: MELISSA
file,'. Phin Ch ,ek
APN: 326 29 022
BP #: W OLI 91, �
- VALUATION: Iso
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: Commercial Building
h 'Ir ;� I _�r'
PENTAMATION
PERMIT TYPE: 1 CBCRW�
WORK
REPAIR E RETAINING WALL 194 LINEAR FT
SCOPE
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addh7 info.
FEE ITEMS (Fee Resolution .11 -033 Eff %!1,x13)
FETE
I'h w1, 1' /wl / /I„
file,'. Phin Ch ,ek
Pe, wi, r
.
ter. Perwir V',,
Suppl. PC Fee: (D Reg. C OT
Olber Ph'mh lnp
Usher Occ. Insp. Li
h 'Ir ;� I _�r'
;'lu+rrl;, i�sp. Fcrr
l;hrc'. lnsp, hee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addh7 info.
FEE ITEMS (Fee Resolution .11 -033 Eff %!1,x13)
FETE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
194 Lf. Retaining Wall
$3,007.00 IRETSTN Standard Retaining Wall
Suppl. PC Fee: (D Reg. C OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:(D Reg. COT
0 p
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
e�: Tax:
El
'U,01W Pce:
0
E)
Work Without Permit? 0 Yes E) No
$0.00
Advanced Plannina Fee:
$0.00
Select a Non - Residential Q
Building or Structure 0
d
i'!:'1 iil,ev.l,r'1 +ir11rr,rr i'e'C_5.
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$3,007.00
TOTAL FEE:
1 $3,007.00
Revised: 08/20/2014