13040088 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19864 WHEATON DR CONTRACTOR:BAY AREA CUSTOM PERMIT NO: 13040088
BUILDERS INC
OWNER'S NAME: JAIDEV PRABHU 1002 S DE ANZA BLVD STE Al DATE ISSUED:04/10/2013
OWNER'S PHONE: 4082502033 SAN JOSE,CA 95129 PHONE NO:(408)446-1200
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIALD
Lia# q `fy REMODEL MASTER BATH 100 SQ FTS REMOVE AND
License Class
g, REPLACE
Contractor A&L, At, C t p tbat 1 1 3 10 WINDOWS LIKE FOR LIKE TO MEET EGREES IN
I hereby affirm t at I am licensed under the provisions of apter BEDROOMS
(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:$12000
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 APN Number:31621085.00 Occupancy Type:
permit is issued.
APPLICANT.CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WIT 80 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)agree to save 180 DA OM 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 Issued b Date44 U 2
granting of this permit. Additionally,the applicant understands and will comply Y'
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date-�? 3 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
Signature of Applicant: Date:
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
I'as of the property,or my employees with wages as their sole compensation,
will do the work,and the structure isnot intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
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 perjuryone 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.emithazardous
Compensation,as providedfor 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
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 the performance of the work for which this
Owner or authorized agent: 'SDate:
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 CONSTRUCTION LENDING AGENCY
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
9.18.
Signature Date
CONSTRUCTIa ��
N PERMIT APPLtCATIaN 0
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTfNO (408)777-3228•FAX(408)777-3333•buildinoCa�cuoertino.oro
❑NEW CONSTRUCTION 1:1 ADDITION ❑ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS /q 0 6 APN#
OWNERNAME '7a I !/e v YQ `_� Y) PHONE lfoS 1 �O-a Q 33 E-MAIL
STREET ADDRESS V1 �l !J CITY,STATE,,ZIP
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OwNER.BUIIAER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
i
COMPANY NA E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK w%,_ l p tv lP� /A C/; -.f n 4, yD- jpe
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NETAREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODELAREA REMODELAREA
PORCH AREA I DECK AREA TOTAL DECKNORCH AREA I GARAGE AREA: LIDETACH
❑ATTACH
#
DWELLING UNITS: IS A SECOND UNrr ❑YES SECOND STORY YES
BEINGADDED? ONO ADDITION? []NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES REC y; L VALUATION:
PLANNING APPL# [:]NO PLANNING APPROVAL LETTER EICHLER HOME? E]NO 77 `Do 0
By my signature below,I certify to each of the following: I am the property owner or autho' e ent 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 d verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil wn. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED p CHECK TYPE R JNG SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit forOVER-THE-COUNTER BUILDING P RE
existing building(s). Demolition permit is required prior to issuance of building VIEW
permit for new building. ❑ EXPRESS PLANNING PLAN REVIEW
—Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11STANDARD ElPUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR 1:1 SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 19864 WHEATON DR DATE: 04/10/2013 REVIEWED BY: MENDEZ
APN: BP#: *VALUATION: $12,000 ll I
%PERMIT TYPE; Building.Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM
USE: PERMIT TYPE: .
WORK. REMODEL M. BATH AND REMOVE AND REPLACE 10 WINDOWS
SCOPE
An
Mech..Plan Check. Plumb.Plum Check Elec..Plan Check
14ech.PerrnitFee: Plumb.Permit Fee: Elec. Permit Fee:
Other:llecrh.Inst). Other Plumh Tnsp. Other Flee.Insp.
A�ech.
Insp.Fee: Plumb. hap.Fee: Elec.Imp.Fee:
NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,etG). Theseees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS(Fee Resolution 11-053 Eff 711112) FEE QTY/FEE MISC ITEMS
Plan Check:Fee: $0.00 100 s.£ Remodel,Bath(<=300 sfl
Suppl.PC Fee:. (E) Reg. OPT "00 $0.00 $600.00 IREMRESBAT
PME Plan Check: $0.00 10 # Window/Sliding Glass Door
Permit Fee: $0.00 $533.00 IWINREP Replacement
Suppl.Insp. Feer Reg. O.OT0,0 hrs $0.00
PME Unit Fee. $0.00
PME Permit Fee: $0.00
Constrztction Tax:
Administrative.Fee:
Work Without Permit? O Yes O No $0.00 O
Advanced Planning_Fee: $0.00 Select a Non-Residential O
Travel Documentation Fees: Building or Structure
Strom Motion Fee: IBSEISMICR $1.20 Select an Administrative Item
Bldg Stds Commission Feer 1BCBSC $1.00
u
$2.201$1,133.00[80- 'IO'Ta $1,135.20
Revised: 04/01/2013
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Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT# �
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR: BUSINESS.LICENSEj#
ADDRESS: CITY/ZIPCQDE:
*Our municipal code requires all businesses working in the city to have a City`of Cupertino:business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S).WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINER A :CITY OF CUPERTINO
BUSINESS LICENSE. G /%� /
I am not using any subcontractor . `
Signature Date
Please check applicable subcontractors and complete the following information.
V SUBCONTRACTOR BUSINESS NAME : BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper g`
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date