11100137I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 869 ALDERBROOK LN I CONTRACTOR: ORE -CON PERMIT NO: 11100137
OWNER'S NAME:
1 MARTINEZ, CA 94553 1 PHONE NO: (925) 8994943 1
k]— LICENSED CONTRACTOR'S DECLARATION
License Class S LLic. t# �?l 7 q1 Y
Contraclor6Ct —Cokj Date /-0
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.
1 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for dre performance of the work for which this
permit is issued.
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
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 whidr may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non�t source rreegulati er the Cupertino upertino Municipal Code, Section
9.18.
Date /0`_l0 l/
❑ OWNER -BUILDER DECLARATION
I hereby affirm that 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 for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed conftactors 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 dre 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, 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
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
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 whidr 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.
JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL
REMODEL 100 SQ FT TO KITCHEN, 1 STRUCTURAL
DOOR
(OPEN LOAD BEARING WALL AND FRAME W/ NEW 2 4X4
POST SUPPORTING A 4X12 HEADER)
Sq. Ft Floor Area: I Valuation: S4000
APN Number: 36920004.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Date:,!�
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I 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 Health & Safety CodeIS
3('and 25534.
Owner or authorized Date/- 11
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Date
CITYOF CUPERTINO
Fm_�FEE ESTIMATOR - BUILDING DIVISION
1AADDRESS:
869 alderbrook In.
DATE: 10/18/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION: $0
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 GENRES
PERMIT TYPE:
WORK
sfd kitchen remodel minor structural.
SCOPE
E3
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer Distric4 School
District. etc.). These fees are based on the nrelimnary information available and are only an estimate. Contact the Dent for addn7 info.
FEE ITEMS (I'ee Resolution 11-053 Eff 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F-1-1 #
$392.00
New Door Opening
1DOORSTRUC Shearwall / Masonry
Suppl. PC Fee: 0 Reg. Q OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
10 ss.f. Remodel, Kitchen (<=300 sf)
$588.00 IREMRES"T
Permit Fee:
$0.00
Suppl. Insp. Fee0 Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee.
$0.00
Select a Non -Residential
Building or Structure
0
0
i
Strom Motion Fee:
$0.00
Select an Administrative Item
Bldg, Stds Commission Fee:
$0.00
SUBTOTALS:
$0.001
$980.00
TOTAL FEE:
1 $980.00
Revised: 10/01 /2011