14110013 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18415 CHELMSFORD DR CONTRACTOR:SARATOGA KITCHEN& PERMIT NO: 14110013
BATH
OWNER'S NAME:
SARATOGA,CA 95070 PHONE NO:(408)867-0771
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
ryry 3 t4 0 REMODEL BATHROOM 221 SQ FT TO INCLUDE M,E,P'S
License Clasp^ Lic.# -7Q'��6 J
Contractor�5��yt.A- }-1?CHE Date ( /3/
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
Jen 3700 of the Labor Code,for the performance of the work for which this APN Number:37522042.00 Occupancy Type:
is issued.
APPLICANT CERTIFICATION
y that I have read this application and state that the above information is PERMIT EXPIRE ISNOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 D YS OF PE T 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 ALLED INSPEC ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequenc e
granting of this permit. Additionally,the applicant understands will comply Issued by: Date:
with all non-point source regulations per the Cupertino cipal Code,Section
9 18.
RE-ROOFS:
Signatu Date 14 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.
❑ OWNE DER DECLARATION
Signature of Applicant: Date:
I hereby affirm th am exempt from the Contractor's License Law for one of
the following two reasons: 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)
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
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 District I .
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapteand
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and:
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued. t �
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 CONSTRU ENDING 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: 18415 Chelmsford dr DATE: 11/03/2014 REVIEWED BY: Mendez
APN: BP#: "VALUATION: 1$10,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex PENTAMATION 1 R3SFDREM
USE: p PERMIT TYPE: i
WORK remodel bathroom 221 sq ft to include m e 's
SCOPE
a J1� Fk
f
'fe %t. Plaut Check Pfriwb.Pleur t:'/tame/, Aiec:.
tler;lr. Perwil Fee: t'lumb. Permit Fee: Peerrsar V,"
lfizc:r
kJe>ch. faaii�. OtherPlumb Im .
F"'(: Ot�itei?r;e. Leeta7:hfecF. (rts• ;t.
NOTE. This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the relimina in ormation available and are onl an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 212 s.f. Remodel,Bath(<=300 sf)
Suppl. PC Fee: Reg. 0 OT 0.0 hrs $0.00 $645.00 1REMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. ® OT Q,Q hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
T—F
("�m_vrvction Tax:
r2t;)llltt.4l1"t:ttf l`c'1"c;'e: 0
Work Without Permit? 0 Yes (j) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Building or Structure 0
7-c lvi Doc°u.imt f2l(vion Fees:
Strong Motion Fee: IBSEISMICR $1.30 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$2.30 $645.00 ToAiJ FEE: $647.30
Revised: 10/01/2014