13050169CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRi• SS: 10250 S TANTAU AVE
CONTRACTOR: TR DEVELOPMENT &
PERMIT NO: 13050169
CONSTRUCTION INC
OWNER'S NAMEi
SAN JOSE, CA 95129
PHONE NO: (408) 329-2831
JOB DESCRIPTION: RESIDENTIAL COMMERCIALS
❑ LICENSED CONTRACTOR'S DECLARATION
Lic # €
DEMOLITION OF 1284 SQ FT SFDWL, ATTACHED
License Class
Contractor s':' 4 1 � � Date ' Z� f1 - c i
GARAGE
260 SQ FT
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: $10000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 37508041.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all. city and county ordinances and state laws relating
WITHIN 0 DAYS OF PERMIT ISSUANCE OR
to building construction,.and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAY OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: Date: 20-3—
granting.of this permit! Additionally, the applicant understands and will comply
with all non point source regulations per the Cupertino Municipal Code, Section
RTiJ ROOFS:
Date I %
Signature'
All roofs shall be inspected prior to any roofing material being installed. If a roof is .
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
L
I hereby affirm that am exempt from the Contractor's License Law for one of
Signature of Applicant Date:
the following,two reasons:! I'
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner: of the propert, or my employees with wages as their sole compensation,
will do the', work and 11 ne structure is not' intended or offered for sale (Sec.7044,
Busines s & Professions Code)
1 1 1
1, as owner, of the piopcq ain exclusively. contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
.
construlct the project ($ec 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
Chapfer;9.12 the
Lhereby affirm under pcuai y of perjury one of the following three
i
maintain compliance with the Cupertino Municipal Code, and
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certifi,eate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
compensation, as p}'ouidod 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
25534.
I have and will maintain worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and
Section,3700 of theial of Code, for the performance of the work for which this
Owner or authorized agent ��- , ��'"t�
permit�sissued. qli
I certify, that. in the pprfoiLance of the work for which this permit is issued, I shall
not Iemploy any person iql any m !nnner so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY
Compensation laws pf California , If; aftermaking this certificate of exemption, I
become subject to the Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
;Worker's
forthwith',comply. with sus h provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
i
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 trig', above', mentioned, property inspection purposes. (We) agree to save
indemnify', ndkeep h the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
less
costs, aln4l:xpensesllw ich %nay acqrue against said City in consequence of the
I understand my plans shall be used as public records.
granting.gf this.pormil(' IAilditionally,l the applicant understands and will comply
with 'all non point sou ce'regulat'ons.per the Cupertino Municipal Code, Section
Licensed Professional .
Signature Date
l�! iilIld,
al
ED
NOTF. This estin, late I does not include fees due to other Departments (I.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Districtete.): These fees are based on the relimina in ormation available and are onlyan estimate. Contact the Deptor addn'1 in o.
FEE!ITEMS!:(Fee'Resolution 11-053 E . 7ff 11112) FEE QTY/FEE MISC ITEMS
Ap Cheek Fed.
77:7-
Sr�ppl.PCFee�
Phunlr/W,Ich./Elec
Permit Fee,,. —'I ''I $534.00
Sup pl!'Imp' Fee': Reg: 0 OT
0.0
hrs
$0.00
�jz�ttab;%i1leclt ;E��ec 'I �
I'lunr,h,/�l ��glt,lElec Pei;inrt Fec.
�onslrziction Tina
Is
A(hni�n.W atrve Fee,
I;�ql j, Gl�itljQ #,Perntif?.
Stron`Ivt to pee
�� 1BSEzsNtzcx
$1.00
Select an Administrative Item
I'
� � tds '�ol{ I � 'Fee• 1BCBSC
mmtssion
$1.00
Iwl)1ra1 �� �' +;�1 �� �' +'1 ;' SUBTOTALS:
$536.00
$0.00 TOTAL FEE,
$536.00
j i,
Revised: 04/29/2013