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12020133 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 848 S STELLING RD CONTRACTOR: PERMIT NO: 12020133 OWNER'S NAME: BECKENHACIER LONNIE A AND DONNA DATE ISSUED:02/29/2012 OWNER'S PHONE: 4082556589 , PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG = ELECT PLUMB '€ License Ct<�s��f �� Lic.# �(�� /� L��_ MECH RESIDENTIAL ' COMMERCIAL 3 Contractor /' C�� Date aG"' �� I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SINGLE FAMILY DWELLING PROPERTY LINE CLEAN OUT (commencing with Section 7000)of Division 3 of the Business&Professions **SEE NOTES** Code and that my license is in fill force and effect. 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 Cade,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:$1500 Section 3700 of the Labor Code,for the performance of the work for which this Permit is issucd. APN Number:35920025.00 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 upon the above mentioned property for inspection purposes. (We)agree to save indemnity and keep harmless the City of Cupertino against liabilities.judgments. WITHIN 180 DAYS OF PERMIT ISSUANCE OR casts,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 perpe upertino Municipal Code,Section J ., Issued by: Dater' 2 77 Signature � �- Dat -,rZ, i ❑ OWNER-BUILDER DECLARATION RE-RQJ!95 � .' All roofs shall tie inspected prior to any r n a,$4 `ng ins ailed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an recti`�: ee ffei*ove all new materials for the following two reasons: inspection. 1,as owner of the property,or my employees with wages as their sole compensation, N w � will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:—,. Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project Sec.7044,Business&Professions Code). ALL ROO 1 CCI�EtRINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.9.5 of the Compensation,as provided for by Section 37100 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 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. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air 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 the performance of the work for which this permit is issued,I shall Health&Safety Code,Section 2.5505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after makingthis certificate of exemption,I n or ho ' age l become subject to the Worker's Compensation pvisions of the Labor Cade,I must Date:0� 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 work'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 county 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 acerae against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION ta with all non-point source reg€rlati;xis 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 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # ; 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35920025. 00 DATE ISSUED. . . . . . . ; 02/29/2012 RECEIPT #. . . . . . . . . : BS000016149 REFERENCE ID # . . . : 12020133 SITE ADDRESS . . . . . : 848 S STELLING RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER BECKENHAUER LONNIE A AND DONNA ADDRESS 848 S STELLING RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4223 RECEIVED FROM . . . . ; KURT M FAULKNER CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1 .00 41 . 00 0 . 00 41 .00 0. 00 1BCBSC VALUATION 1, 500 .00 1.00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 1, 500 .00 0 .50 0 . 00 0 .50 0 .00 1PPERMITFE FLAT RATE 1 .00 44 . 00 0 .00 44 .00 0.00 1PRSEWER UNITS 1 .00 22 . 00 0 .00 22 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 44 .00 0. 00 44 .00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 152 . 50 0 .00 152 .50 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING 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: r C, PERMIT# OWNER'S NAME: ?�^ PHONE# GENERAL CONTRACTOR: // BUSINESS LICENSE# 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 INSP4CTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTJI2ACr �1RS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. / I am not using any subcontractors: �_'�L 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 Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERT{NO (408)777-3228• FAX(408)777-3333• building(dtugerhno.org MISC PLUMBING ❑MEaiAMCAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS C Lb C)C, C £I I I A i�; APN# /7 r' _ r / OWNER NAME PH f" f/J E-MAILS STREET ADDRESS Wil) Y 1� C. . I n C CITY.SLATE,ZIPrte) r 1 (j FAX 1 CONTACT NAME PHOT� � ._ _ (�, / E-MAIL STREETADDRESS I ( J CITY.STATE, ZIPS r. FAX ' (� �` i ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 01 CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENMNEER ❑ DEVELOPER ❑ TENANT CONTAACTOA NAME ' / LICENSE MNBW CLC. LI;'QISE.TYPE SUS.LIC# 1 COMPANY NAME E-MAIL FAX STREET ADDRESS l CITY,SLATE, rr ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,TIP PHONE USE OF URI.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YFS BT=ING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLIIt HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is orrect.,j have read Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating ding c tructio �u representatives of Cupertino to enter the e-id �ropert`yJfor inspectio pud:f) Signature of Applicant(Agent !C/ Z j "' Date: y v' - l/� SUPPLEMENTAL INFORMATION REQUIRED =2--VA-ONLY � OVER-THE-COUNTER c ❑ EXPRESS x U W ❑ STANDARD U ❑ LARGE a FEI MAJOR MHPMiscApp_20ILdoc revised 06/21111