15040065 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11621 SEVEN SPRINGS DR CONTRACTOR:THD AT-HOME PERMIT NO:15040065
SERVICES,INC.
OWNER'S NAME:
ATLANTA,GA 30339-3913 PHONE NO:(510)731-1004
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E]
REPLACE 1 (E)WINDOW&2(E)SLIDING GLASS DOORS,
License Class G t Lic.# <q 3602— i LIKE FOR LIKE
Contractor T M D t? V4 7 M2. Date Lf r
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
Co sation,as provided for by Section 3700 of the Labor Code,for the
e ance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4695
v and will maintain Worker's Compensation Insurance,as provided for by
ct n 3700 of the Labor Code,for the performance of the work for which this APN Number:36652049.00 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 WIT180 DAYS OF IT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter LED INSPECTI N.
upon the above mentioned property for inspection purposes. (We)agree to save 18 rAYS F
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ¢sem
costs,and expenses which may accrue against said City in consequence o the 1 S J
granting of this permit. Additionally,the applicant understandscomply
with all non-point source regulations per the Cupertino M al Code,Section
918.
f RE-ROOFS:
Signature Date 1( 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.
❑ kons:
-BUIL DECLARATION Date:
Signature of Applicant:
I hereby affirm empt from the Contractor's License Law for one of
the following ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code) HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
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. 1 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 Dis ' I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Cha .12 and
the Health&Safety Code,Sections 25505,25533,and 25534.
I have and will maintain Worker's Compensation Insurance,as provided for by j f's
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: Y /
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 CONSTRUCTI ING AGENCY
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 I hereby affirm that there is a construction lending agency for the per
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
918.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 11621 SEVEN SPRINGS DR DATE: 04/08/2015 REVIEWED BY: MELISSA
APN: 375 35 045 BP#: "VALUATION: $4,695
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION 1GENRES
USE: SFD or Duplex PERMIT TYPE:
WORK REPLACE 1 E WINDOW&2 E SLIDING GLASS DOORS LIKE FOR LIKE
SCOPE
r mak '
Meds. Plan Check PftEruh.Plan Check 1.7ec.Plzen Check
Aleck. Permit Fee' Plumb. Permit Fee: Llec. Permit Pee
Other!llct h.Insyi. ED
Other Plumb Inii other ISlec.Ins/..
Mech. lnsp. Fee: Plumb. hasp. Fee: l lec.Insp. Hee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS(Fee Resolution 11-053 E . 711/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 3 # Window/Sliding Glass Door
Suppl.PC Fee: (F) Reg. ® OT 0.0 h �-00 rs $0.00 $43WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee-.0 Reg. ® OT O,Q hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C�;onstruction Tax:
0
Administrative Fee:
Work Without Permit? ®Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Building or Structure �
Truvel Documentation Fees: �
Strong Motion Fee: IBSEISMICR $0.61 Select an Administrative Item
BldgStds_Commission Fee: 1BCBSC $1.00
.d T AL E:
$ ' $432.61
.:
_ 1.61 $431.00 . ..
Revised: 04/01/2015