11080169CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20200 PATRIC CT
OWNER'S NAME:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class ,,pe Lie. # "
Contracto�7g! &"/,.t om % � Dater 23 /
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.
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
permit is issued.
APPLICANT CERTIFICATION
1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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. �
Siggature ( ✓�- �"� ` �`—�`- Date e/ 34
G OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
Owner or authof' agent:
forthwith comply with such provisions or this permit shall be deemed revoked. _ Date: i3
CONTRACTOR: COSTA BELLA BUILDERS PERMIT NO: 11080169
PO BOX 2963 DATE ISSUED: 08/23/2011
SANTA CRUZ, CA 95063
PHONE NO: (831) 818-9847
BUILDING PERMIT INFO: BLDG f- ELECT r- PLUMB F
MECH r RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: KITCHEN REMODEL(1 IOSQFT);NON-STRUCTURAL -
REMOVE
CBINETS,APPLIANCES,FLOORING & SOME
PANELING.REPLACE WITH NEW UPDATE LIGHTING TO LED &
Sq. Ft Floor Area: ( Valuation: $15760
APN Number: 36935013.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued `Y' r- "" Date:
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
APPLICANT CERTIFICATION
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
in, ify and keep harmless the City of Cupertino against liabilities, judgments,
CL ad expenses which may accrue against said City in consequence of the
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.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I I understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
t FEE ESTIMATOR - BUILDING DIVISION
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the Dept_for addh7 info.
FEE ITEMS wee Resolution 11-053 Eff7,i1i111
ADDRESS: 20200 patric ct.
DATE: 08/23/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION: 1$15,760
'PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Jar.;wh 111"
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
kitchen remodel non structural.
SCOPE
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the Dept_for addh7 info.
FEE ITEMS wee Resolution 11-053 Eff7,i1i111
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
a
Remodel, Kitchen (<=300 sf)
Jar.;wh 111"
0.0
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the Dept_for addh7 info.
FEE ITEMS wee Resolution 11-053 Eff7,i1i111
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
110 s.f.
$588.00IREAmESKIT
Remodel, Kitchen (<=300 sf)
Suppl. PC Fee: O Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:O Reg. 0
OT
0.0
hs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
("fw?siYwcfio"T1`t
Acoustical Fee:
0 Yes O No
$0.00
0
O
Work Without Permit? 0 Yes O No
$0.00
Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
O
0
T_,,, , ,-�f3,
7 .,: , £, r �Irf7{:.it'If.,/r 3 `1 �' �'r. t
Strong Motion Fee:
IBSEISMZCR
$1.58
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $2.58
$588.00
TOTAL FEE:
$590.58
Revised: 07/04/2011