12010019 CITY OF CUPERTINO BUILDING PERMIT
BIIILDING ADDRESS: 19911 FIG TREE CT CONTRACTOR:SEARS HOME PERMIT NO: 12010119
IMPROVEMENT
OWNER'S NAME: C(-INNINGHAM-SHEFFER CATHERINE M TRUS 1024 FLORIDA CENTRAL PKWY DATE ISSUED:01/18!2012
OWNER'S PHONE: 4084462247 LONGWOOD,FL 32750 PHONE NO:(925)245-2000
LICENSED CONTRACTOR'S DECLARATION
-
C( BUILDING PERMIT INFO: BLDG ELECT ' PLUMB '
-I
License Class Lie.#
� Date MECH ' RESIDENTIAL COMMERCIAL
Co n tracto,(�
I hereby affirm that I am licensed tinder tile provisions of Chapter 9 JOB DESCRIPTION:REPLACE SLIDING GLASS DOOR AT DINING ROOM
LOCATION
(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 tinder 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:$2221
Section 3700 of tile Labor Code,for the performance of the work for which this
permit is issued.
APN Number:31630080.00 Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
Up011 the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued b Date:
Signature Date Ob
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I alit exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and(tic structure is not intended of offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
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 tinder penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. twilt illaintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should t use equipment or devices which emit hazardous air
Section 3700 of(tie Labor Code,for the performance of the-work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in(lie performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to becorne subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Own t:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of vw)rk's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and count%,ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
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 ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31630080. 00
DATE ISSUED. . . . . . . ; 01/18/2012
RECEIPT #. . . . . . . . . : BS000015774
REFERENCE ID # . . . : 12010119
SITE ADDRESS . . . . . : 19911 FIG TREE CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CUNNINGHAM-SHEFFER CATHERINE M
ADDRESS . . . . . . . . . . : 19911 FIG TREE CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : IE INC
CONTRACTOR . . . . . . . ; ALFRED W NYMAN JR - ASST SEC LIC # 23097
COMPANY . . . . . . . . . . : SEARS HOME IMPROVEMENT
ADDRESS . . . . . . . . . . ; 1024 FLORIDA CENTRAL PKWY
CITY/STATE/ZIP . . . : LONGWOOD, FL 32750
TELEPHONE . . . . . . . . : (925) 245-2000
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 2,221 .00 1.00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 2,221 .00 0.50 0. 00 0 .50 0 .00
1WINREP EACH 8 1 .00 392 . 00 0. 00 392 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 393 . 50 0 .00 393 .50 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 393 . 50 #13039
---------------
TOTAL RECEIPT 393 . 50
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
1 ADDRESS: 19911 fig tree ct. DATE: 01/18/2012 REVIEWED BY: bobs.
APN; BP#: IVALUATION: 1$2,221
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY raFD or Duplex PENTAMATION 1GENRES
USE; PERMIT TYPE:
WORK replace sliding lass door at dining room location.
SCOPE
Ll Li
A10TE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ure,based on the relimina in ormation available and are only an estimate. Contact the Det or addn 7 info.
FEE ITEMS fl' 7 r-'11; FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 L-Lj # Window/Sliding Glass Door
Suppl.PC Fee: Q Reg. 0 OT 0.4 hrs $0.00 $392.00 1WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. Q OT4.4 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? d Yes 0 No $0.00
_.._......_....._._........_._.__._......_._._.._.._..._.__..__._ $0.00 Select a Non-Residential.
Building or Structure a
_<' ;r wi't !">r ' „ IBSEI,S'AKCR $0.50 Select an Administrative Item
t onnirnission Fee, IBCBSC $1.00
SUBTOTALS: 1 $1.50 $392.00 TOTAL FEE: $393.54
Revised: 1/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: Tree 6't' PERMIT#
OWNER'S NAME: U PHONE# qV8 *49- Z.z y7
GENERAL CONTRACTOR: S 1GM�/JUrX1� BUSINESS LICENSE #
ADDRESS: () p5C) *-fUU CITY/ZIPCODE: �C�`Gtpc-�'+ C; 4� `
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. M4Af
I am not using any subcontractors: v j -J
Signature Date
Please check applicable subcontractors and complete the following information:
s/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting
Linoleum /Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
/.,�, C)/ co� I 1 01
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDiNG DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255
408 777-3228• FAX(408)777-3333-b0ding(5cupertino.org misc
CUPERTiNO ( )
[]PLUMBING ❑MECILAMCAL []ELECTRICAL- ®MISCELLANEOUS
PROJECT ADDRESS l(�^ I �)e ' ,{ AFN# -
oWNERNAME �� (,ldl(�� U$ �Yb'ZZ`�7 E-MAII
STREErADDRESS I/re�,. C`,� Cmr,�srArE, n J,Sud c1 FAx
1�Q 11 Y� i✓� tai wc� h `1 7
CONTACT NAME PHONE E-MAIL
S'IREETADDRESS CrN,STATE. 21P FAX
❑OWNER ❑ OWNER4R LDER ❑ OWNER AGENT awmACrDR ❑cmrrmCTORAGENT ❑ AxcmTscr ❑ENumEm ❑ DfvmwE;L C3 TmAm
CONTRt.CTORN .`,M �� n LICENSE NU� 3 I10E�TYPE BULIC#
CC.1Q�i1�5 ``'f l,,_ 1rn ��v f+K tf
COMPANY NAME E-MAIL FAX
STREET ADDRESS r, r �Q S A_' �W CITY.STATE.ZIP t,7 n 3 PgRT' �30'3y?s 3
ARCHTIEC IENGINEEj NAME LICENSE NUMBER(J` I �i BUS LIC#
R
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY.STATE,ZIP PHONE
USE OF %SFD.OUPLEx ❑ MULTI-FAMILY PROJECT iIN WILDLAND ❑ YES PRaJEcT ua ❑YES LS THE BLDG AN ❑YES
BUILDING ❑COMMERCIAL URBAN UMRFACE AREA ❑NO FLOOD ZONE ❑NO EICHI,FR HOME! ❑No
DESCRUMON OF WORK
io Door
TOTAL VALUATION. a , RECEIVED BY:
ILL
By my signature below,I certify to each of the following: I am the property owner or anthorized agent to act on the property owner's behalf I have read this
application and the information I have provided is corzect,j have read the Description of Work and`�fY it is accmaiG I agree to comply with all applicable local
ordinances and state laws relating m build' constivctioti I�autrhorize representatives of Cupertino to eater the above-identifiedes.
property for inspection purpos
Signature of Apphcant(Ageat! vl ""'a Date.
SUPPLEMENTAL INFORMATION REQUMED OFFICE 47,Ofty
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MEPMrscApp Z011.doc revised 06121111