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09100016I CITY OF CUPERTINO BUILDING PERMIT 1 I BUILDING ADDRESS: 940 PROVIDENCE CT I CONTRACTOR: TBD - TO BE DETERMINED I PERMIT NO: 09100016 1 I OWNER'S NAME: TEDINUCHIDA I I DATE ISSUED: 10/05/2009 1 f'"'NER'S PHONE: 4089219292 Li LICENSED CONTRACTOR'S DECLARATION License Class ('—/0 Lic. # _6y 4 � 3 Contractor ✓V C ik 09_ OC46C79flOate %O - s' I 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. 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. I 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. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is correct. 1 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 harnless 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature_(:: - Date V .s OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 Section 3700 of the Labor Code, for the performance of the work for which this 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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 upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, -ind expenses which may accrue against said City in consequence of the ug of this permit. Additionally, the applicant understands and will comply With all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date /0 OCII PHONE NO: BUILDING PERMIT INFO: BLDG F_ ELECT F_ PLUMB r- MECH i- RESIDENTIAL r- COMMERCIAL F_ JOB DESCRIPTION:200 AMP SERVICE CHANGE Sq. Ft Floor Area: I Valuation: $2500 APN Number: 35611057.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 D S FROM L T CALLED INSPECTION. Issued by: /�• Q Date: RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Ownero thorized a ent: \ /� U c�-•c --� Date CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35611057.00 DATE ISSUED.......: 10/05/2009 RECEIPT #......... BS000008821 REFERENCE ID # ... 09100016 SITE ADDRESS .....: 940 PROVIDENCE CT SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER TED TSUCHIDA ADDRESS 940 PROVIDENCE CT CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM GUS KANAKIS 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 ---------- ----------------------- 1BCBSC VALUATION ---------- 2,500.00 -------------------- 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 2,500.00 0.50 0.00 0.50 0.00 1BUSLIC FLAT RATE 1.00 114.00 0.00 114.00 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- ---------- 199.50 0.00 199.50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE -------------------- NUMBER ----------------- --------------- CREDIT CARD 199.50 AMEX --------------- TOTAL RECEIPT 199.50 H. CITY OF CUPEf�TINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM 09 L C�o 0 t ('0 APN # _ �'"�� t v 2j q! U c� 1 Date: �j 015101 Building Address:9 :Vo /�f 0V/-0 C7- J# Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes El No HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Owner's Name: 1,--7 -�� /-� ✓ -�/ tai/-�VJk-t' Phone #: q Contractor: L Phone: Fax: Contractor License #: Jc 6 c( -+ �-3 Cupertino Business License #: Contact: //��'' G Phone: qo,Y Fax: < Residential Comme cial Job Description: ),03 S�"%L `/1 C C CO-" & F Building Permit Info: Bldg ❑ Elect"M Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B)& Valuation: C- - Square Footage: } � J 2 [project Size: Express ❑ Standard ❑ Lar e ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at Revised 07/14/09 51,20 i -11 CITY OF CUPERTINO CITY OF CUPERTINO GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) additional stucco application B 1 WINREP Replacement windows/sliding glass door (ea 8 windows) B 1 WINMEWSTR New Window -structural shear wall/masonry (includes plan ck fee) B l J 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min when not over counter) Standard Plan Check (when no E/M/P) hourly -stand alone B 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1TRAVDOC Travel & Documentation B 1BUSLIC Business License B 10 E�M MU& D� CITY OF XPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: C 67 -'PERMIT # OWNER'S NAME: s- c 14-1 ✓J PHONE # C) GENERAL CONTRACTOR &VGre�'� c=r-71etc, I FAX # I am not using any subcontractors: Signature Date Please check apnlicable subcontractors and complete the following information: (f5-� -/0- S-- o Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile (f5-� -/0- S-- o Owner/ Contractor Signature Date