15040048e
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 15040048
10171 VICKSBURG DR CUPERTINO CA 95014 (369 07 006)
HOMEOWNER
BUILDER
OWNER'S NAME: AIJAIED SALLAM
DATE ISSUED: 12/21/2016
OWNER'S PHONE: (408)-644-6338
PHONE NO:
LICENSED COMRACTOR'S DECLARATIaN
BUILDING PERMIT INFO:
License Class Lic. #
Contractor HOMEOWNER BUILDER Date
—BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
— MECH — RESIDENTIAL"— COMMERCL4,L
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations:
ADD 239 S.F. TO 1ST FLR TO EXPAND (E) FAMILY RM &
CONVERT (E) BDRM TO LIVING RM & ADD 85 S.F. PORCH.
1. 1 have and will maintain a certificate of consent to self -insure for Worker's
CONSTRUCT (1) SECOND STORY (1293 S.F.) WITH 3
Compensation, as provided for by Section 3700 of the Labor Code, for the
BEDROOMS & 3 BATHROOMS. RE -ROOF (E) 7 SQ'S
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, forthe performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $337000.00
APPL.ICrANT 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
APN Number:
Occupancy Type;
representatives of this city to enter upon the above mentioned property for
36907006
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.
PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 12/21/2016
Issued by: ABBY AYENDE
OWN R -B Tli D .R DECLARATION
Date: 12/21/2016
1 hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RF -ROOFS:
1. I, as owner of the property, or my employees with wages as their sole
All roofs shall be inspected prior to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered for
installed without first obtaining an inspection, I agree to remove all new materials for
sale (Sec.7044, Business &Professions Code)
inspection.
2' % I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
Signature of Applicant:
Date: 12/21/2016
i hereby affirm under penalty of perjury one of the following three declarations:
i. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Compensation, as provided for by Section 3700 of the Labor Code, for the
Performance of the work for which this permit is issued.
z' I have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code, for the performance of the work for which this
I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
a. I certify that in the performance of the work for which this permit is issued, I
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & Safety Code, Sections 25505, 25533, and 25534.
be deemed revoked.
APPLICANT CERTIFICATION
Owner or authorized agent:
I certify that I have read this application and state that the above information is
Date: 12/21/2016
correct. I agree to comply with all city and county ordinances and state laws
CONSTRUCTION LENDING AGENCY
relating to building construction, and hereby authorize representatives of this city
I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We) agree
of work's for which this permit is issued (Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Name
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
Lender's Address
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
,-
ARCHITECT'SD . RATION
I understand my plans shall be used as public records.
Signature.s Date 12/21/2016
Licensed
Professional
CITY OF CUPERTINO
FFF FCT11%/FAT0R — RTTII DING DIVISION
ADDRESS: 10171 VICKSBURG DR
DATE: 04/07/2015
REVIEWED BY: MELISSA.
APN: 369 07 006
BP#:
-VALUATION: $337,000
`-PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY
Sor Duplex
2nd Unit? Yes No
PENTAMATION
1 R3SFDADD
.USE::
I
OTC., 0 Yes No
PERMIT TYPE: 19
wORK
ADD 239 S.F. TO IST FLR TO EXPAND E FAMILY RM & CONVERT E BDRM TO LIVING RM &
SCOPE
I ADD 85 S.F. PORCH. CONSTRUCT (N) SECOND STORY (1293 S.F.) WITH 3 BEDROOMS & 3 p
TYPE OF FLR AREA
OCCUPANCY TYPE: PC FEES PC FEE H) BP FEES BP' FEE ID
CONSTR. sf.
R-3 (Custom) 11-B,111-B,IV,V-B 1,617 $2,798;41 1R3PLNCK $2,183.37 IR3INSP
I TOTALS: I 1,617I $2,798 41 _ I
$2,183.37
1Tlech. Plan Check
!l1i>c , Permit Fee:
Other ilech. Aup..
Meech. Itzsp. Fee:
NOTE: This estimate does not
f'fzunb, Flan C: hec ' I
Plumb. Permit Fee: --
Other Plumb Imp.ET-L
P111717b, 111SP. ["Ce:
fees due to other Departments (a. e. Planning;
District, etc.). These -fees are based on the MliminarJ
FEE ITEMS jFee Resolution 11-053 E . 711113)
Plan Check Fee:
Suppl. PC Fee: (j) Reg. 0 OT
0.0
hrs
PME Plan Check:
Permit Fee:
Suppl. Insp. Feer Reg. 0 OT
0.0
hrs
PME Unit Fee:
PME Permit Fee:
Constructi.on .Tax:
Adininistralive F %:
Work Without Permit? 0 Yes (F) No
Advanced Planning Fee: IPLLONGR
l r uvel .Doeumenta ion Ff ees:
Elec. Plan Check
Elea Permit l=ee'
Other Elec. 1nsv.
Elec, Invp, Fee:
Works, Fire, Sanitary Sewer District, School
ormation available and are only an esumate. t -onset ine uepc iur uuuis
FEE QTY/FEE MISC ITEMS
$2,798.41 = s.f. Re -roof
$0.00 $119.00'1RER00ERE,
$0.00
$2,183.37
$0.00
$0.00
$0.00
$0.00
Strong Motion Fee: IBSEISMICR $43.81
Bldg Stds Commission Fee: 1BCBSC $14.00
'UBTOA- $5,265.97 $119.00
a
Select a Non -Residential E)
IBuilding or Structure
Select an Administrative Item
W1 "$5,384.97
Revised: 02/14/2015