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14120005 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10531 MADERA DR CONTRACTOR:FIREPLACE ELEMENT PERMIT NO: 14120005 TRADISTONE OWNER'S NAME: SIMONE&DROR HAROUSH 2444 OLD MIDDLEFIELD WY DATE ISSUED: 12/01/2014 OWNER'S PHONE: 6507731772 MOUNTAIN VIEW,CA 94043 PHONE NO:(650)938-2000 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL ❑ TAP IN TO(E)GAS LINE&INSERT(N)FIREPLACE License Class_ Lic.# (•� INSERT PER MANUFACTURES SPECS ContractorgA*I,Sli6p_., Date 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. Sq.Ft Floor Area: Valuation:$8500 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:32635028.00 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 ALLED 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 7i (' ate: 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. / RE-ROOFS: Signature Date la / 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. ❑ 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(Sec.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 I 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 25505,25533,and 25534. // Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: 1,4 Date: A M 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 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 — 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9 18. Signature Date CONSTRUCTION PERMIT APPLICATION O COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 1� 10300 TORRE AVENUE•CUPERTINO, CA 0,5014-3255 (408)777-3228•FAX(408)777-3333•building CUPERTINO a(�cupertino.orp ❑NEW CONSTRUCTION ❑ ADDITION ❑ALTERATION/TI ❑ REVISION/DEFERRED�j ORIGINAL PERMIT# PROJECT ADDRESS APN# 3 OWNER NAME �fqo, t� PHONE/6 ji) 7� 7 E-MAIL STREET ADDRESS 15 /I/1 V CITY,STATE,ZIP FAX CONTACT NAME n PHONEEpp p E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT 41 CONTRACTOR NAME 10,Q" '"C. LICENSE NUMBER / LICENSE TYPE BUS.LIC# COMPANY NAME I �• ,"L E-MAIL 'n STREET ADDRESS CITY,STATE,ZIJP/�y/sJ;1)7j,,V tjl ot�,` // Spl•✓,_V q•/��� FPAHXQ NE/ ' ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# 1 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE/ DESCRIPTION OF WORK —F�ovi -eoc ,e& I l C �rci� � L l EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO - TOTAL AREA AREA 11 AREA NET AREA BATHROOM - KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECKAREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH []ATTACH #DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES °z _ TOTAL VALUATION: PLANNING ADPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO © Tv By Iny signature below,I certify to each of the following: I am the property owner or authorized agent to ac on the property owner's behalf. I have read this application and the information I have provided is correct. I have read t escription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t Id/in onstruction. Ize representatives of Cupertino to enter the b1ove entif d r rty for inspection purposes. Signature of Applicant/Ageat: ` �/ Date: SUPPLEMENTAL INFORMATION REQUIRED 02.1_ �PI:ANROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for r �O R TBE-COjIN�'ER���'a •�BUILbI1�G PLANREVIEW ` w; existing building(s). Demolition permit is required prior to issuance of building a0, permit for new building. fxPRE�3 x �L�NI\mc PLAN xEviEw _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure r%Xyl n "r Exi liBilc ivoRlts form if any Hazardous Materials are being used as part of this project. s ' �Iy.F� _Copy of Planning Approval Letter or Meeting with Planning prior t0 � MASOR�}.,��' �x sQ SANIT'ARX SER'ERDISTRICT submittal of Building Permit application. fxr* r s BldgApp_201 1.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10531 MADERA DR DATE: 12/01/2014 REVIEWED BY: MELISSA APN: 326 35 028 BP#: `VALUATION: 1$8,500 xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPGAS USE: p PERMIT TYPE: WORK TAP IN TOE GAS LINE & INSERT N FIREPLACE INSERT PER MANUFACTURES SPECS SCOPE y ROM`e .�, e�cry, Ulmer Che c�1< Plumb.Plan Check 0.0 hrs � $0.00 Eiec- 1,an(,heck Fee: Plumb.Permit Fee: IPPERMIT i:'=e'. 1'"r-1,3i.i e C)1<cWe-h, h�ig) F1 L Other Plumb Insp. 0.0 hrs $48.00 C)i1,>< 1,k:(,Irr"?. Lj I,�sp_i��f�: Plunib� Iras��. Tee: Alec.13 ,, 1 e: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the relimina information available and are onlyan estimate. Contact the Det or addn'l info. FEE ITEMS (Fee Resolution 11-053 E f 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Plumbing Suppl.PC Fee: (j) Reg. 0 OT 0.0 1 hrs $0.00 $72.00 IPGASRES Piping,Gas<=4 Outlets PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes (E) No $0.00 Suppl. Insp. Fee:Q Reg. ® OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure A Strong Motion Fee: IBSEISMICR $1.11 1.0 hrs Inspections Bldg Stds Commission Fee: IBCBSC $1.00 $143.00 ISTINSP Inspection,Hourly $143.11 $215.00 - TOALFEE: $358.11 Revised: 10/01/2014 e troy vQvro vs r'C ,'deoce— C4, &.4D -<-odle-.s Cac)j3) �p4 CUPERTINO a; 9uilding Department J :-r.,^Mj Ih � 4� of ftl epi"!4:o, � M,14 v �e 1 J�,cc r V REVIEVVED FUR CODE COMPLIANCE e(em CGL r is P/1 Reviewed By. �----. 3, K-&- aA— PS I[1te— C (pfs +PlOVI CO NITY DEVELOPMENT DEPARTMENT BUILDING DIVISION - CUPERTINO APPROVED .4 J( rhis set of plans and specifications MUST be kept at the J r loS� ob site during construction. It is unlawful to make any ` rS ��'�r, V changes or alterations on same, or to deviate erefrom, with approval from the Building Official. .amping of this plan and specifications SHALL NOT e held to permit r to be an approval of the violation �� s provisions f or state Law. Y MW ao 7 uVA IV' s, �LA6�- vi f << ---- COPY