11110033CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1119 KENTWOOD AVE I AND CONTRAI row LETELIER PATRICK) A I PERMIT NO: 11110033
—NERS NAME:
I CUPER INO CA, 95014-5807 I NONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class - Lie.4
Contractor
Date
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 farce 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 salf-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 Ore work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and stale 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.
BUILDING PERMIT INFO: BLDG fi ELECT r PLUMB r
MSCI{ r RESIDENTIAL r— COMMERCIAL
JOB DESCRIPTION: REPLACE f:XIS'I INC;
Sl IOWlilt,WA'I ERCLOSE'T,SINK(SOSQFf);
LOCA IIONS & PLOOR PLAN TO REMAIN Tlft, SAME
Sq. Ft Floor Area: I Valuation. $1000
APN Number: 35931007.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date I
Issued by:
OWNER -BUILDER DECLARATION
1 hereby affirm (hat 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 far 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,) 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
forthwith comply with such provisions or this permit shall be deemed revoked.
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
on the above mentioned property for inspection purposes. (We) agree to save
unify and keep hon less the City of Cupertino against liabilities, judgments,
Mrs, 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 -paint source regulations per the Cupertino Municipal Code, Section
9.18.
Date:
RF. -ROOFS:
All roofs shall be inspected prior to any roofing material beug installed. If a root' is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
RA7.ARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilea Ith& So feq• Code, Sections 25505, 25533, and 25534. ]will maintain
compliance with the Cupet!dno Municipal Code, Chapter 9.12 and the Health &
Safely Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should 1 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
Ilealth & Safety Code, Sections 25505, 25533, and 25534.
Date:.
,7 -------
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is tit construction lending agency for the performance of cork's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCIIITECT'S DECLARATION
I understand my plansshall be used us public records.
Licensed
Fm
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
WOrirt otr ►_ Thv_ev fooc aro hacod an tho nrolininaru infarmalian availahlo and oro only an a_etimaly_ Contort tho Dont fnr adds'/ info_
FEE ITEMS (Lee Resolution 11-053 La.. 7/1/11)
ADDRESS: 1119 kentwood ave
DATE: 11/03/2011
REVIEWED BY: larry s
APN:
BP#:
"VALUATION: 1$1,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
0.0 1
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
replace existing shower, water closet sink. locations and floor plan to remain the same
SCOPE
$0.00
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
WOrirt otr ►_ Thv_ev fooc aro hacod an tho nrolininaru infarmalian availahlo and oro only an a_etimaly_ Contort tho Dont fnr adds'/ info_
FEE ITEMS (Lee Resolution 11-053 La.. 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
50 7 s.f. Remodel, Bath (<=300 so
$588.00 /REMRESBAT
Suppl. PC Fee: Q Reg. 0 OT
0.0 1
firs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -.0 Reg. Q OT
0.0 1
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
�.CAx1; f`i°t'fFttii 107.1 7_1
0
Work Without Permit? 0 Yes (E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Q
0
I
1.
Stronp, Motion Fee: 1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
1 $1.00
...::.....:.::::::::...:.:.:.::::...::::...'?..
$1.50'
,.f..,
$588.00
$589.50
Revised: 1010112011