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15060012 (3) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22706 MEDINA CT CONTRAC/TyOR: �A_ �06� PERMIT NO: 15060012 t'G�lk �oln r� OWNER'S NAME: JEAN MARIE MERKHOFER DATE ISSUED:06/02/2015 PHONE NO: O ER'S PHONE: 4085683507 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E] p REMODEL(E)MASTER BATH,85 S.F.,NO STRUCTURAL License Class : Lie.# 0 � CHANGES Contractor ' Datel 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 1I 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 APN Number:34215055.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is tIssue . XPIRES OT STARTED correct.I agree to comply with all city and county ordinances and state laws relatingAYS OF 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 saveF A ED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments J� costs,and expenses which may accrue against said City in consequence of t ate: 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. r � f ( RE-ROOFS: Signature ! /�/1 �1 Date L 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 Date: Signature of Applicant: 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 BETTER 1,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) HAZARDOUS MATERIALS DISCLOSURE I,as owner of the property,am exclusively contracting with licensed contractors to 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,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized agent: 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 CONSTRUCTION LENDING AGENCY 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 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 918. Signature Date GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE e CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•building( CUPIRRTINt cupertino.org Alit 506 06 9 Z ❑PLUMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS C ', APN N 3►`7 I Z ` l J <J OWNER NAME I PHONE{�0� / . E-MAIL STREET ADDRESS G CITY, STATE,ZIP �� ! ( 1 i � �D FAX CON(TACT NAMEPHONE E-MAIL ,k U( STREET ADDRESS I f� CITY,STATE,ZIP L� FAX ❑ OWNER ❑ OMWER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER - ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME r ! I ' � LICENSE NUMBER j LICENSE TYPE n BUS.LIC 3 COMPANY NAME J6 E-MAIL (� f� FAX STREET ADDRESS 4 L b(r�.(l(f U I7 9 CITY,STATE,ZIP n !r�D rip 1 J � PHONE ARCIETECT/ENGIIQEEIR NAME I V LICENSE NUMBER l 1l BUS.LIC n I COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FA7,7II.Y PROJECT IN WILDLAND ❑ YES PROJECT 1N ❑YES IS THE BLDG AN ❑ YES BLTILI).IG: ❑COMMERCIAL URBAN INTERFACE AREA E] NO FLOOD ZON'B ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK VP(ft�-Pd -- IkWf- Add I A 2r-el Z 2S SqP TOTAL VALUATIO • C p Q-6 RECEIVED Bl ; � NFo �3 By my signature below,I certify to each of the following: I am the property owner or authorized Q act on th s application and the information I have provided is correct. I have read the Description of Work and ac omp able local ordinances and state laws relating to building construction. I a thorize representatives of Cupei mo to enter the above-identifie i spection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL TIFORMATION REQUIRED h x F o ONE= z a � >OVER3THE COTTER, ga MRI Oilz IINANN A1EPA scApp 2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION kDDRESS: 22706 MEDINA CT DATE: 06/02/2015 REVIEWED BY: MELISSA PN: 34215055 BP#: 'VALUATION: $10,000 PERMIT xPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY PENTAMATION 1 R21SFDREM USE: SFD or Duplex PERMIT TYPE: TY WORK REMODEL E MASTER BATH 85 S.F. NO STRUCTURAL CHANGES SCOPE Nfech. Plart Check Plumb. flan Check Elec.Plan Check tbfech. Permit Fee: Plumb.Permil Fee Elec. Permit Fe... Ocher 1,1ech. Insp. EIFL_ Other Plumb Insp. Other Elec.Insp. Lj I.1ech. hap.Fee: Plumb. hap. Fee: Elec.Insp.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 prelimina information available and are only an estimate. Contact the Dept-for addn7 info. FEE ITEMS Lee Resolution 11-053 E{. 7f /1/ FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.0085 .00 s.f. Remodel,Bath(<=300 sf) Suppl.PC Fee: Reg. 0 OT 0.0 hrs $0.00 $645IREMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl.Insp.Fee-0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Aclinlnlstrative Fee: 0 Work Without Permit? 0 Yes (F) No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential 0 Building or Structure 0 T ruvel Doculnenfallon Fees: Strong Motion Fee: IBSEISMICR $1.30 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 ;SUBTOTALS:; $2.30 $645.00 TOTAL FEE.', $647.30 Revised: 05/07/2015 t I I _ - - - Cl1PERT NQ -! .9utldrnq DeQa�rtmeni XZ -- - - ---------- v V I ��1n9 V I EW E U AN ,,F- i -Revs` wed B _Tv I I I I i �'V— J i AI n i l�V p ENT BllILD DIVIS9IpN CUPERTINO I I I T01, of plans and specifiic ions MUST be kept-atbe - t dun{tg ebrytr�ctiorl_1t isnla_w_ful to make an - - - - �, l u ^__._ __ __ _changes or al:terattons on same or to deviate therefrom, without approua�fironi-the 8uitd'in Offi�ta Tb Stamping p 9 — - -- - - rof this Ian and spzcfica ,ons_,SHAL NOT _ -- - - to an approval of the Violation held to._ e to Law cf rov rdinance or Sta PE_ RMIT _- I r e -(1q I t-H]Ctic__- Q_t,_�� ' h 1 -- t��°'�.._ 5 � �'= __��'�' -l�C'�GI �ow, ---