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12090046 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20648 SHELLY DR CO\IRACI'OR:ANTHONY HODDER PERMIT NO: 12090046 CONSTRUCTION OWNER'S NAME: JACKSON WILLIAM D AND JACQUELI 7504 BOLLINGER RD DATE ISSUED:09/07/2012 OWNER'S PHONE: 4085045257 CUPERTINO,CA 95014 PlIONE NO:(408)2574317 ❑ LICENSED CON•IRAC`F{OR'S DECLARATION .1011 DESCRIPTION: RESIDE\PIAL 11 CO\IJIERCL\I, License Class?➢I �� c.9 ( l REMOVE AND REPLACE SHOWER STALL& TILE FLOOR �� 2 EXHAUST FAN, VANITY IN M.BATHROOM to Contracr: Uv`-c-1 ��"Date hereby affirm that I ma licensed under the provisions (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 cervi Bcate 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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$5000 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 AI'N Number:35915006.00 Oecupancy'I'ype: permit is issued. .\PI'LIC.\�t'C.ER'I'IFICA'1'ION I certify that I have read this application and state dial the above infomhation is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I aggro to complywith all city mid county ordinances and state Imes 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 DA ' F OM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilitics,judgments, costs,and expenses which may accrue against said City in consequence of the rte,/,//,/f �7 grunting o(this r tit. Additionally,the applicant understands and will comply Issued by: f / , h Date: < with all non- int ource regulaZZ— tiahs per the Cupeni o Municipal Code,Section 9.18. Rb:ROOFS: Signntu All roofs shall be inspected prior to my 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 Signalurc of Applicant: Date: hereby affirm that I am exempt from the Contractor's License Low for one of the following two reasons: ALL ROOF COVERINGSTO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole comp:nsation, 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 IL\"I,ARDOUS MAT'F,RLU S DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have rend the hazardous materials requirements under Chapter-6.95 of the California Ilealth&Safety Code,Sections 25505,25533,and 25534. t will I hereby affirm under penalty of perjury one of the following three maintain compliance with the CupertinoMunicipal 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 1 use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of die Labor Code,for the air contaminants as defined by the tiny Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliancewith ih pertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sect' ns 55 3.and 25534. ,L Section 3700 of the Labor Code,for the performance of the work for which thisQ Owner or authorized agent pemtit is issued Dole: I certify that in the performance of the work for which this permit is issued,l shall 6v not employ any person in my manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRl1CTION 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 APPIACANTCERTIFICATION Lender's Address I cenify 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCDITECI••S DECLARATION 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 aMlicmt understands and will comply with all non-point source regulnticns per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION :121 ADDRESS: 20648 Shelly Dr DATE: 09/07/2012 REVIEWED BY: Mendez APN: BPH: 'VALUATION: $5,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: WORK REMOVE AND REPLACE SHOWER STALL & TILE FLOOR EXHAUST FAN VANITY SCOPE Mech. Plan Check Plumb. Plan Check Flee.Plan Check Mach. Permit Fee; Plumb. Permit Fee: Elec.Permit Fee: Orher Much. Insp. Other Plumb Insp. Li I Olhcr Elec.Insp. ,Meeh.Insp. Fee: Plumb. htsp. Fee: Flee.insp.Fee: NOTE: This eatinrate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Smtitay Sewer District,School District,etc.). These feev are based on the prelintinan information available and are ontr an ettinmte. Contact the De t or adrin'I info. FEE ITEMS (Fee Resolmion 11-053 EIC 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. Q OT 0.Tilts $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: Hourly Only? O Yes Q No $0.00 Suppl. Insp. Fee0 Reg. Q OT 1 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tam: Administrative Fee: Q Work Without Permit? O Yes Q No $0.00 E) Advanced Planning Fce $0.00 �2 hours Inspections E) Travel Docranentation Fees: $266.00 /STINSP Inspection, Hourly 0 Strong Motion Fee: IBSEISdIICR $0.50 F0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fcc: IBCBSC $1.00 $42.00 IADMIN SUBTOTALS: $1.50 $308.00 TOTAL FEE: $309.50 Revised: 07/01/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ^ G 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408) 777-3228• FAX(408) 777-3333• buildinclecuoertino.oro 444 CUPERTINO ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT4 PROJECT ADDRESS ZO ..�.SQ✓-1 �4, APN 4 15 CC n i7/ OWNER k 1 'Py✓4_ CE-MAR. 6Y `�Z-5 STREET ADDRESS "rlCITY, FAX CONTACT NAME PHONE *[ E-MAIL STREETADDRESS CITY,STATE, ZIP FAX 0 OWNER ❑ OWNER-BUI.DER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT 0 ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRA RNA E LICENSENUMB R LICENS E I BUS.LIC II COM NY tyAt Vv 'C(-dC✓ /rr�`S 1 E-MAIL FAX a1�Gt N l 1 STREII�0n (�OL_��EIL �� CI TATE,ZIPV n PHONE ARCHITECT/ENGINEER NAME LICENSENUMBER GG.Y BUS.LICK COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK e w-T,�-� G.-••—�1 R e a-u �� 5774-c c -r- (.�-�. �loarz EXISTING USE PROPOSED USE CONSTR.TYPE M STORffS USE TYPE OCC. SQ.Ff. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REA/ODEL AREA PORCH AREA DECK AREA TOTAL DECKMORCH AAEA GAKAGEAREA: UDETACH ❑ATTACH 0 DWELLING UNRS: ISASECONDUN'IT ❑YES SECONDSMORY ❑YES BEING ADDED' ONO AUDITION' ONO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF ISTIIEDLDGAN ❑YES @RECEIVED;BYr 'n', v-f�—�-^.,,,;�r -TC!J4t VALUATI00 PLA.NNINGAPPLM ONO PLANNING APPROVAL LETTER EICHLER HOME' ONO CJ� By my signature below,1 certify to a of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this application and the information I h• a ovided is c rect. I have read t Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws relatin o b Ildin pion. I autho ze •prels mit'es of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: i/ _ Date: SUPPLEMENTAL INFORMATION REQUIRED " =�°zNC Il" 'f rrr t� Y .;al I'L'AN CII t:CK;I'1'1'E� New SPD or Multifamily dwellings: Apply for demolition permit for F ' r '° ' -�'"q?�9j••�--' "-s-^ � - t� 'r e ❑❑ O\Eit'1 UI COIL\Pik t Itr ❑pBUILDING PIA\kltlrWfi 4, §'LLB existing ermit for bu5ldiDemolition permit is required prior to issuance of building �"... epi kiss '� P g ❑ 1 LA\\I\C rL''Y\REY a w�, _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure O siA\unkU g ;y., ,o , ❑lat UBLIC W ORhS; 7ss '� �-i vt Corm if any Hazardous Materials are being used as part of this project. tit, 1}�❑t 41kGK y ❑IFIRE DEPT _Copy of Planning Approval Letter or Meeting With Planning prior to F Rr we ` •a 4 rs 'T'1 { - ' submittal of Building Permit application. ❑rs>,a'Lolic }� ArYr�„w ^' I ❑`4SA\ITARY'.SE\S ER DISTRIGq BldgApp_2011.doc revised 06/21/11