12070185 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18385 CHELMSFORD DR CONTRACTOR: PERMIT NO: 12070185
OWNER'S NAME:
PHONE NO:
❑ - LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL0
License Class Q , ic.N ea/q//Z REMOVE AND RELOCATE(1) DOO12 AND(I) WINDOW,
/%iCONSTRUCT INTERIOR LANDING FOR NEW DOOR
Contractor Date 13 ?Da LOCATION
I hereby affirm that I am ceased under the provisions of Chapter 9 AND RELOCATE EXISTING SWITCHES
(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
perfornnaice of the work for which this permit is issued. Sq. Ft Floor Area: Valuation:$6000
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 ,UPN Number:37522039.00 Oceupanry Type:
permit isissued.
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 lays relining 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 thej3 7-�7- I
granting of this permit. Additionally,the applicant understands and will comply Issued by: VVVVVV
CT Date: 000 _
with all non-point source r qulq/iens per the Cupertino Municipal Code,Section
9.18.
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
0 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 BEEPER
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)
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
Thereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: Ilealth&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 Munic'pal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code.Sections 25505.2 j'.3; nd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this " �'
Owner or authorized agent:
! Date: -777—�/Z
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,atter 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
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 18385 Chelmsford Dr. DATE: 07/24/2012 REVIEWED BY: Sean
si�rr APN: BP#: *VALUATION: $6,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE:
1GENRES
WORK Remove and relocate (1) door and (1) window, construct interior landing for new door location and
SCOPE recloate existing switches.
4
Mech. Plan Check Plumb. Plan Check I J Elec.Plan Check
Mech. Permit Fee: Plumb.Permit Fee: Elec. Permit Fee:
Other Mech. Insp. Other Plumb!nsp. Other Elect Map.
Mech. Imp.Fee: Plumb. hip. Fee: Elec./asp. Fee:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning. Public Works, Fire,Sanitary Sewer District,School
District.etc.). These fees are based on the preliminary information available and are onto'an estimate. Contact the Dept for athht'!info.
FEE ITEMS free Resolution 11-053 Eff 7/l/1/) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 J 2 J # Window/Sliding Glass Door
Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0:00 $400.00 I t1'!NREP Replacement
PME Plan Check: $0.00
Permit Fee: Hourly Only? 0t'es 0 No $0.00
Suppl. Insp. Fee:0 Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax: J
Administrative Fee: 0
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Fee: $0.00 1 hours Inspections
Travel Documentation Fees: $133.00 ISTIASP Inspection, Hourly 0
Strong Motion Fee: !BSE/SAI/CR $0.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00 r1)35• Ce
SUBTOTALS: $1.60 $533.00 TOTALFEE: $534.60
Revised: 07/01/2012