10020034 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 10222 NILE DR CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10020034
OWNER'S NAME: JOHN LEE DATE ISSUED:02/04/2010
PER'S PHONE: 4082575691 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT[_ PLUMB
License Class Lic.# MECH r RESIDENTIAL F COMMERCIAL
Contractor Date
JOB DESCRIPTION:2 TOILETS,REPLACE THE CARPETW/LINOLEUM FLR
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions &SHOWR
STALL(56SQ)
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.
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 Sq.Ft Floor Area: Valuation:$9500
permit is issued.
APPLICANT CERTIFICATION APN Number:36950018.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: � "c=- . Date:
Signature Date
lFi OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or o d t: L/
forthwith comply with such provisions or this permit shall be deemed revoked. Date: � C
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
nnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
.and expenses which may accrue against said City in consequence of the
gt,mting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date 2/4 pp Licensed Professional
lS
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIZ RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk:: Lot:
APN 36950018 . 00
DATE ISSUED. . . . . . . : 02/04/2010
RECEIPT #. . . . . . . . . BS000009694
REFERENCE ID # 10020034
SITE ADDRESS 10:?22 NILE DR
SUBDIVISION . . . . . . .
CITY CU?ERTINO
IMPACT AREA . . . . . .
OWNER JO-IN LEE
ADDRESS 10222 NILE DR
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2144
RECEIVED FROM JOHN LEE
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
____ ____ ---------- - ---------
---------- ----
1BCBSC VALUATION 9, 500 . 00 1 . 00 0 .00 1. 00 0 . 00
1BPFIXTURE NO OF FIXTURE 2 . 00 16 . 00 0 . 00 16 . 00 0 . 00
1BSEISMICR VALUATION 9, 500 . 00 1 . 00 0 . 00 1. 00 0 . 00
1INSPMIS HOURS 1 . 00 126 . 00 0 .00 126 . 00 0. 00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 ----- 0_00
..--------- ---------- ----------
TOTAL PERMIT 228 . 00 0 .00 228 . 00 0 . 00
METHOD OF PAYMENT AMOUNT -- -
REFERENCE NUMBER
----------------- ---------------
CHECK 228 . 00 #2226
---------------
TOTAL RECEIPT 228 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
__ -------- ----------------------------
-- ---------------------
100 FOOTINGS 102 PIERS
104 REBAR 301 ROUGH PLUMBING
302 TUB & OR SHOWER 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 305 FRAME
307 INSULATION 308 SHEETROCK
309 EXTERIOR LATH 310 INTERIOR LATH
311 SCRATCH COAT 505 FINAL ELECTRICAL
CITY AFy
CITY OF CUPERTINO
ADDITION/REMODEL
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Is a 2" unit being added? Yes ❑ No If yes, p lease fill out the permit application for 2" unit.
Building Address:
102 Z Z Jv/le pry ve, �
Mailing Address(if different from building address):
Owner's Name: John L ec Phone# :(4q) ZS ,_ S6 T/
Contractor: � -1-Do( Tiff �lit1�'1 Phone#: U -
VIC e'"al R 14110 Trvias Fax#: (OD$ - 3 ?�
Contractor License#: C4 wfe,
Cu ertino Business License#:
31,6- $30 S Phone#: yD ) 3, - S
Contact: 08Fax#: �!D S - 7
i
Building Permit Info:
Bldg. ED,--` Plumb. Mech. ElHillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled(not including addition)?
Z -FDilets , Yeplq&e the &a►mt w;1%h l%holeurM -00-DY 4
Remodel Includes Re-Roof: Yes ❑ No �i] If yes list number of squares
Remodel Includes Structural: Yes ❑ No [fir
Do you have the pre-application planning app roval? Yes ❑ No ❑
If yes, please provide a copy of your planni!lg approval.letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath 5,6 Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V B rz.31dent0
Valuation: $(Tt� Please check this box if the project is a
i second-story addition ❑
Project Size: Ex ressStandard ❑ Lar e ❑ Major❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set&the sheet index.
***For Office Use Only*** Revised 07/06/09
Over-the-Counter ❑
CITY OF CUPERTINO
ADDITON/FXMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
S Ft
1REMRES2 Remodel Resident-al B
Greater than 1000 sq ft
1REMRES3 Remodel Resident.al B
Greater than 2500 sq ft.
1REROOFRES Residential Re-roc f Each B
100 SF
REMODEL PLNCK
1 STPLNCK(1-3 for Standard Plan Check B NOT FOR OVER THE
remodel) COUNTER PLAN CKS.
WINDOW/SLIDING 1R3SFDREM
GLASS DOOR
1 WINREP Replacement windows B
(ea 8 windows)
1WINNEWNSTR New Window (ncn- B
structural)
1WINMEWSTR New Window (Structural B
Shear Wall/Maso )
1WINBAYSTR Bay Window (Structural) B
SKYLIGHTS 1R3SFDREM
1 SKYL<10 SF Skylight less than 10 sf B
IS YL>IOSF Skylight greater than 10 B
sf or structural
1STAIRS Stairs-first flight ea addt'l B
IEP FEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permi:Fee P
IELCPLNCK Stand Alone Electric Pln E
Ck(hourly)
CITY OF (;UPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1MECPLNCK Stand Alone Mi;chanical M
Pln Ck(hourly
1PLMPLNCK Stand Alone Plumbing P
Pln Ck (hourly)
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
E Commission Fete
1BSEISMICRE Seismic Residential B
ITRAVDOC Travel &Documentation B
IBUSLIC Business License B
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