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09090107 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19028 TILSON AVE CONTRACTOR:ROBERT TEMMERMAND PERMIT NO:09090107 OWNER'S NAME: ROBERT TEMMERMAND 19028 TILSON AVE DATE ISSUED:09/15/2009 ER'S PHONE: 4087258543 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:METER RELEASE (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 Sq.Ft Floor Area: Valuation:$100 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 APN Number:37509007.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR 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 FROM LAST CALLED 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 r p granting of this permit. Additionally,the applicant understands and will comply Issued,by: Date: "lJ with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is .[J OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: I,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, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 1 have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air I have and will maintain Worker's Compensation Insurance,as provided for by 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 Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall O er or a th ed agent: not employ any person in any manner so as to become subject to the Worker's no Date: !S 12pp 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 CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. 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.) APPLICANT CERTIFICATION Lender's Name 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 Lenders Address to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION nify and keep harmless the City of Cupertino against liabilities,judgments, c 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-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. y �A SignatureA CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY ## 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37509007 . 00 DATE ISSUED. . . . . . . : 09/15/2009 RECEIPT #. . . . . . . . . BS000008682 REFERENCE ID # . . . : 09090107 SITE ADDRESS . . . . . : 19028 TILSON AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ROBERT TEMMERMAND ADDRESS 19028 TILSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : R GO TEMMERMAND CONTRACTOR LIC # *OWNER* COMPANY ROBERT TEMMERMAND ADDRESS 19028 TILSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 100 . 00 1 .00 0. 00 1. 00 0 . 00 1BSEISMICR VALUATION 100 . 00 0 .50 0 . 00 0.50 0 .00 1EPERMITFE FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 43 .50 0 . 00 43 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 43 .50 AMEX --------------- TOTAL RECEIPT 43 .50 CITY OF CUPERTINO CUPEf�TINO GENERAL BUILDING PERMIT APPLICATION FORM APN# / �5D Date: vo-1 ' c>L Se -f Building Address: 9©2 $ ,' 1 soh ve Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes ❑ No HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Owner's N e: _ Phone#: Kabee- 1 4b$ 72 Contractor: Phone: �� Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial Job Description: Vw e t e-`^ l e q Building Permit Info: Bldg ❑ Elect 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: � Square Footage: Project Size: Express O,,-�tandard ❑ Large ❑ Maj or ❑ 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 www.buildit reen.or Revised 07/14/09 { CITY OF CUPERTINO Cin OF GENERAL BUILDING APPLICATION CUPEf�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 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 1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 5 of 5 OWNER-BUILDER VERIFICATION 1. (Check one) I or myimmediatefamily (parent, spouse or child) will perform: A. " All the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City Phone Number Type of work to be erformed ......................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (r verse side). Property Owner's Signature: d Date: 26,0 Job Address: 1 cey 2 3 T, '1 S76 Permit# �� 0-7 Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. _