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12090047 CITY OF CUPERTINO BUILDING PERMIT RUILDING ADDRFSS: 10340 P11AR LAP DR CONTRAC`T'OR:-T49--T"E PFRSIIT NO: 12090047 Dt-.rte_ OWNER'S NANI F: 0V VLAC-6 r-) PIIONE NO: ❑ INCENSED CONI'RACI'OR'S DECLARA'T'ION JORDF.SCRIPTION: RESIDEN"i"AhU CONINIERCIALL) License Class Lie.# 9 y-S(a8S KITCHEN REMODEL 180 SQFT, REMOVE AND REPLACE 3 WINDOWS AND 2 PATIO DOORS Contractor"R C ME tJ15-1L Date " 1 ^ (1_ hereby affirm that I am licensed under theprovisions 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 self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for whichthis permit is issued Sq.Ft 1400r•Area: Valuation:$75000 1 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:32639031.00 Occupancy Type: permit is issued. ,\I'1'LICANT CPSR'I'IPIC.\TION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.1 agree to comply with all city and county ordinances mid state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agrce to save 180.DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the �_�N yq TG� Date: / ',6 ya granting of this permit. Additionally,the applicant understands and will comply' Issued by: !ll����rrr«< Q with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signmure Date _ 1^I•�1 All roofs shall be inspected prior to any inning material betel;installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection, ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: hereby affirm that I am exempffrom the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETI"ER I,as owner of the property,or my employees with wages as their sole comTrnsation, 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 IL\%\RDOUS MATERLU S DISCLOSURE construct the project(Sce.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 NI unici pal Code,Chapter 9.12 and the declarations: Ilealth&Safety Code.Section 25532(x)should I store or handle hazardous 1 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 Nlanagement District pedormmue of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for tlhe performance of the work for which this cx1-_l,L permit is issued. Owner or authorized agent Date: I certify that in the performance of the work for which this permit is issued,I shall not employ my person in my manner so as to become subject to the Worker's Compensation laws of Cali forma. If,after making this certificate ofexemption,I CONS'IBIICI'ION LF;NIIINC ACENCI' 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. w'ork's for which this permit is issued(Sec.3097,Civ C.) Leader's Name APPLICANI'CERTIFICATION Lender's Address I certify thin I have read this application and state thin the above information is correct.1 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 ,\RCIII"1"ECT'S DECLARATION and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may aceme 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 12 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10340 Phar Lap Dr DATE: 0 910 712 01 2 REVIEWED BY: Sean APS: BP#: VALUATION: $75,000 *PERMIT TN'PE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM USE: p PERMITTI'PE: WORK Kitchen remodel 180 sq ft remove and replace 3 windows and 2patio doors. SCOPE Much. Plan Check Phmrh. Pion Cheek Elec. Plan Chock blech. Permit Fee: Plumb.Pennir Fec: E1ec. Permit Fee: Odmr Alech. Insp. Other Plumb Insp. Ll Other Elce.bup. Alech.Insp. Fee: Plumb. br,.p. Fee: Elec.Insp.Fee: NOTE: This estimate noes not include fees due to other Departments(i.e. Planning, Public {forks, Fire,Sanitary Sewer District,School District. etc. . Thesefees are based on lite preliniinarj information available and are only an estivate. Contact the Dept for arhbr7 info. FEE ITEMS (Fee Resohuion 11-053 F . 771/1 U FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 180 s.f. Remodel, Kitchen (<=300 so Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $600.00 IREArRESKIT PME Plan Check: $0.00 5 IN Window/Sliding Glass Door Permit Fee: $0.00 $400.00 1 1 rr9NREP Replacement Suppl. Insp. Fee:Q Reg. I) OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consnvtetion Tree: Achniuistrative Fee: 0 Work Without Permit? O Yes Q No $0.00 (D Advanced Planning Fec: $0.00 Select a Non-Residential E) Building or Structure Travel Documentation Fees: A Shone Motion Fee: IBSEISAIICR $7.50 Select an Administrative Item Bide Stds Commission Fee: IBCBSC $3.00 SUBTOTALS: $10.50 $1,000.001 TOTAL FEE: $1,010.50 Revised: 0 7/0112 01 2 CONSTRUCTION PERMIT APPLICATION a" COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION '(�O 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 n GV CUPERTINO (408) 777-3228• FAX (408) 777-3333• buildingecupertino.oro \( ' ❑NEW CONSTRUCTION ❑ ADDITION 14 ALTERATION/TI El REVISION/DEFERRED ORIGINAL PERMIT N PROJECT ADDRESS 1,0'3 +D Ih A'~ LAP C (Z-, APNN 32-(-o39 03 OWNER NAME AI � STREET ADDRESS CITY, STATE,ZIP FAX sA,vw C. p Ttllo 95 01 CONTACT - G!94M CAMptSYJ A.16 J SoS6 CA 9S 1 L� v6 7-6,6-( .OS I C1 owNER ❑ OwNER-aunDER ❑ OWNERAGENT Iti-CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHDECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CO TRACTOR NAME PC �E�-'( LICENSE NU ER LICENSE TYPE BUS.LIC 9 G MG j6L CflJ>�Rva� (o � $ If (a$� $ 110o COMPANY NAME E-MAIL FArX, A �. EZ lC�@ G-I`-1 18 C-T'i �01177 STREET ADDRESS Y STATE,Z P ONE (o5e6 Car�D6N A-67f5A �o�s C� �1 S 12J oQ 221 ^ 197o ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS,LIC 0 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE.ZIP PHONE DESCRIPTION OF WORK �6Mnt7bL KI ( � i Ex! I USE PROPOS USE CONSTR. PE tSTORIES I VVV USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN OTHER REMODELAREA/a0O REMODELAREA REMODELAREA PORCHAREA I DECK AREA TOT.ALDECK ORCHAREA GARAGEAREA: LJDETACH E]ATTACH d DWELLING UNITS: IS A SECOND USTT LJ YES SECON'DSTORY [I YES BEIN'GADDKD? E]NO ADDITION? EINO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED. TOTAL VALUATION: PLA.NNMGAPPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? []NO 3 eA4 ,"h-+� By my signature below,1 certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. thorize representatives of Cupertino to enter the ore-identified property for inspection purposes. Signature of Applicant/Agem: SUPPLEMENTAL IN FORr\1ATION IRED (?F-�cr'-c-a*r:7 7= —. ,tom <s"'-" -" `''0 '"' .-. ;,ilLAN.CHECK�n'PEIa'7-.,-,:�:C._`.33�pj HouT�NC sLIP,L.'� _New SFD or Multifamily dwellings: Apply for demolition permit for ot. ❑�i. 4 '�e Hu I�u existing building(s). Demolition permit is required prior to issuance of building permit for new building. `❑ I xI Rtss R,1`F'1 .', , ' ❑"❑ I IaNNnc I I AN REVIEW IFN�T Commercial Bldgs: Provide a completed Hazardous Materials Disclosure „ '–A" fo— rm p b i if any Hazardous Materials are being used as part of this project. ❑O II vucT; z:�4 •.t'"j ,© ,I IRT m I r„ - �D�'' _Copy of Planning Approval Letter or Meeting with Planning prior to t❑ MnloR > t,s y,,,., rrd ❑ SANII UR SEN ERDISrR IGT submittal of Building Permit application. ;io a 4,. ;t°tj.�Y ��-❑O^�nrino F ini'HenLTHt,v,'_, BldgApp_201 1.doc revised 06/11/11