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15040061 CITY OF CUPERTINO BUILDING PERMIT CONTRACTOI PERMIT NO: 15040061 BUILDING ADDRESS: 11129 SUTHERLAND AVE ')A JOE lr ACI DATE ISSUED:04/08/2015 OWNER'S NAME: TANI STEVEN N AND PATRICIA D PHONE NO: OWNER'S PHONE: 4082545004 JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL LICENSED CONTRACTOR'S DECLARATION REMODEL(E)BATHROOM,NO STRUCTURAL CHANGES License Class Lic.# O / 1 1 2—9 (52 WO I+ S.F.) ,,��// Contractor I�I A�V E I ! 1 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 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 ompensation,as provided for by Section 3700 of the Labor Code,for the Valuation:$4800 rformance of the work for which this permit is issued. Sq.Ft Floor Area: ve and will maintain Worker's Compensation Insurance,as provided for by e ion 3700 of the Labor Code,for the performance of the work for which this APN Number:35617063.00 Occupancy Type: pe it 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter ALLED INSPECTIO . upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FRO indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ssue Date: granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code.Section 918. RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is :�O installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER- ER DECLARATION Signature Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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) HAZARDOUS MATERIALS DISCLOSURE I,as owner of the property,am exclusively contracting with licensed contractors to 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 perjury one 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 emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the ir�contaminants maintain compliance=ENDING Air Quality Management Chapter District and performance of the work for which this permit is issued. the Health&Safety Cod ,and 25534. I have and will maintain Worker's Compensation Insurance,as provided for byi f 1Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agDate: �fpermit 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 COG AGENCY 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 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.) forthwith comply with such provisions or this permit shalt be deemed revoked. 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 918. Date Signature c_p GENERAL PERMIT APPLICATION Is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildincl(ftupertino.org MISC CtJi�EtrtTlM�t4 0-PLUMBING CRANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESSI r �I C� C APN# / — 1 OWNER NAME ?A--r �{•- 1?rI G rA IA-AID �`� " �V�j� E-MAIL j STREET ADDRESS CITY,S TE�ZIP �� FAX CONTACT NAME JEFF RAINEY PHONE 510-427-4260 E-MAIL jeffrey.rainey@att.net STREET ADDRESS 1069 EDGEMERE LANE CITY,STATE,ZIP HAYWARD, CA 945454 FAX510-783-1041 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR C4 CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CON'�RA�CNvrR NAL 6/"` ��' I LIC S ELR LI ENSETYPE BUS.LIC# A I COMPANY NAME 4,'JL) 1 ,AYl67(4 E-MAIL FAX STREET ADDRESS /� d t�' �J �T CITY,STANT�EOZIP_7 C A Ca iL Z/� s,o•396 122 ARCHITECTIENGINEER NAME T t-IV 1 LICENSE NUMBER /T /T /O BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX [I MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO 7 FLOOD ZONE ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORKe ' r I 1`�� t I I I A)S UI'r� A-G 2 r L !3 ^/ j i- 0j2-2,- J✓ cit S 7 -r, /r. 1" tA-11 /Je-0 JAA)lT G4­351A)CT �I -r F(Y7e, -roI CZE" TOTAL VALUATION: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the p 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. onze representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: PLEMENTAL INFO REQUIRED OEBICE,IISE ONLY W D OVER-THE-COUNTER ❑`D EXPRESS i WW STANDARD U 'LARGE IA MAJOR MEPMiscApp_201 Ldoc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION 7ADDRESS: 11129 SUTHERLAND AVE DATE: 04/08/2015 REVIEWED BY: MELISSA 356 17 063 BP#: *VALUATION: $4,800 PLAN CHECK TYPE: Alteration/Repair *PERMIT TYPE: Building Permit pENTAMATION PRIMARY 1 R3SFDREM USE: SFD or Duplex PERMIT TYPE: WORK REMODEL E BATHROOM NO STRUCTURAL CHANGES 52 S.F. SCOPE Plumb.Plan Check Elec. P/un Check Mech. Plari Check Alech.Permit Fee: Plumb. Permit Fee: lslec_ Permir Fee: Oil rer-;llec�h. hasp. Other Plumb Inslr. 011ier tilec.in 11eclz.Ins/). Fee: t'harrib. hasp. Fee: llec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(i.e Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These fees are based on the preliminaryin ormation available and are onlyan estimate Contact the Dept or addn'l info. FEE ITEMS (Fee Resolutit11-053E FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 52 s.f. Remodel,Bath(<=300 sf) Supp/.PC Fee: Reg. $0.00 $645.00PME Plan Check: $0.00 --T7=Permit Fee: $0.00Suppl. Insp.Fee:Q Reg. $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ("Onstrttc°tion :lax Administrative. Fee: Work Without Permit? ® Yes 0 No $0.00 • Select a Non-Residential 0 Advanced Planning Fee: $0.00 Building or Structure 0 i ?ravel Docaunzenlation Fees: Select an Administrative Item Strong Motion Fee: 1BSEISMICR $0.62 Bldy,Stds Commission Fee: IBCBSC $1.00 - 17 646.62 $1.62 $645 00 _ n $ Revised: 04/01/2015 :....... 13/ ..ter , ......;. ... .... ............. ......................... ...... ...... . . . . . . . ............ ............. i.... &AhdnW .l. .. .... ... .. .. .. .. .. - - . .. ... -. �y y�.�jj'g �p ........... .. . ... . .. ..:. . b� 0 -• ....... /� :........... :..... ...... .... . . ........... .... ..... . ...... ...... ...... ... ....... ..... . 1i.. -k .. 34:7 .. ... .. .. .. _ . .... ....... .: ....:... 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COMMUNITYLMENT DEP r bEVELQP BUILDING bIVISlO ARTMENT X N-CUPERTINO �.T~^� APPROVED This set of Plans and Specifications MUST be kept. lob'` fir' construction. it is unla�t-,ul to at the chb';' *5 oj`aiterations on same there, male any ,� >� �f�om, witi'out a ,or to dF.,,e � L: c } app, from the Building ¢ The sta ,inn Of this Plan and d �C3frrcial. be h oecifications SHALL NOT 'qi0� rc,t G, o e 4 Pr anal of t;;to r . --1 viui,�tian -- din e or Sate Law. ®� DATECD 0 PERFoIT NO, J t .. ...' I.... .............. .... . . .................. ........................ ..... ........................ 111 .... e� ... .. ................. ..... ..... .. ...:......:......:....::......:......:......:.....:........... ... ...:.... .. .. .. .. .. ... .. .. . .. .. .. .. .. .. ... .. .. .. ... ... .. .............. .. . .. .: .. . .. .. .. . .. . .. . .. .. .. . .. .. ..:.. ..:.. .. .. :. . .. .. .. .. .. :. Iy � :.. ..:.. ... :. .. .:.. ..:.. ..:.. ..:.. .. . a GG ...... ..... ... .. .. .. .. .:.. ..:......:.... .. .. .. ..... :.....:..... ......:...... ... .. ............ .. .. .. .. _.. .... :. :.. ..: C� :............ ..... .....:.....:.....:..... ..... . ...:........... HOT NATE::... . .. : . ..... .