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15060101 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10211 DENISON AVE CONTRACTORApV-9 W, � PERMIT NO: 15060101 OWNER'S NAME: HILL JANICE TRUSTEE �� MqQ DATE ISSUED:06/15/2015 OWNER'S PHONE: P,NJ CA 4761M PHONE NO: v LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑ � �, BATHROOM REMODEL(65 S.F.)-ADD NEW SHOWER, License Cla s - Lie.# _ a. _ FLOORING,VANITY,FANLIGHT,REMOVE POCKET DOOR Contractor AND INSTALL NEW SWING DOOR 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 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:$15000 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:31628021.00 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 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)agree to save 180 D S FROM LAST CALLED INSP T N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applican understands and will comply Issued by: Date: with all non-p int source regulations p r e Cup o Municipal Code,Section 9 18. Xr RE-ROOFS: Signature ' = — Date' �= l j 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 DECLARATIO I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 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 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 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,Se 'ons 25505,25533,and 25 34. Section 3700 of the Labor Code,for the performance of the work for which this "r�'" r permit is issued. Owner or authorized agent: - - Date: IP$ 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255C5/`/,.,n I CUPERTINQ (408)777-3228• FAX(408)777-3333•building(cDcuoertino.org l��ffVV'��'' ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECTADDRESS /b Il ` { A 40 so 1 P \ APIA m l u OWNER NAME PHONE I E-MAIL to STREET ADDRESS / �� ��� C 5�(TEdZ �� / FAX CONTACT NAME t�A L-/ PHONE r�SN1o2�? E�tr� TREET ADDRESS v, 1 �f CITYFAX CA ❑ OWNER ❑ OWNER-BUILDER ❑ OHT'ERAGENT AICONTRACTOR ❑CONIRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT NTRACTORNAME LICENSE NUMBER iqI z 6 LICENSE TYPE � BUS.LIC R COMPANY NAME E � � STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTIENGLNEER NAME I �J� LICENSE NUMBER BUS.LIC n COMPANY NAME V E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK � � -� ^ ' r Q U0b(Z- w w wMMA EXISTING USE PROPOSED USE CONSTR.TYPE STORIES USE I TYPE OCC. SQ.FT. VALUATION(S) AREA G + NAREA OOR�/' DAO TNEI'OTAL AREA BATHROOM. r KITCHEN., OTHER, REMODEL AREA l-L/& REMODEL AREA REMODEL AREA PORCHAREA DECK AREA TOTAL DECKIPORCH AREA GARAGEAREA: ODETACH . ATTACH . DWELLING FITS: ISA SECOND UNrr ❑YES SECOND STORY DYES BEING ADDED? NO ADDITION? NO PRE-APPLICATION El YES .IF YES,PROVIDE COPY OF IS THE BLDG AN/`�•�t❑YES `Fz~ CEIVED`BY t y„ TOTAL VALUATION: PLANNING APPL r-1NO PLANNING APPROVAL LETTER I EICHL£R HOME? ❑NO _ _ t � r By my signature beloNv,I 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 ve provided is correct. I have read the Des cri n of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws r u'ding constru I au Nee re res n 've of Cupertino to enter the above-ident+ified property for in purposes. LO Si�natureofApplicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED + . r �,� PI ARCICKTl�?E-F rte_.+ New SFD or Multifamily dvvellings: Apply for demolition permit for `I]SovER rH co�T7hTER fl WB v> c PL REVIEW= existing building(s). Demolition permit is required prior to issuance of bulldmg - It l ON A �.1 .y permit for new buildingA. ��S��ExPx�ss rt r0 PLAhfiZRGPL4NREVIEFV "`7`�SFr �,•'� ti _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure © sTr>3vnATZD �� PIIa3Lcwoxxs.` form if any Hazardous Materials are being used as part of this project. �2 RX � SREDEPS _Copy of Planning Approval Letter or Meeting with Planning prior to SA"I�'i3'./iItYSER�R•DTST•RICT' - submittal of Building Permit application. •c �: - y �+ ""E - a„�:=,.rte v+ �D��`ETa'VIROh'MENTAL,I�EAZTH BIdg,Ipp_2011.doc revised 0 612 1/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10211 DENISON AVE DATE: 06/15/2015 REVIEWED BY: PAUL APN: 316 28 021 BP#: 5 *VALUATION: 1$15,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM USE: PERMIT TYPE: WORK Bathroom remodel 65 S.f. -Add new shower, flooring, vanity, fan/light, remove pocket door and install SCOPE new swing door Nfech. Plan Check Phuub.Plan Check blec..Plan Check :Tech. Peralit Fee: Plumb. Permit Fee: Eke. Permit Fee: Other illech. Insp. Other Plumb Insp. Lj Other Elec.Insp. 11 ech.Insp. Pee: Phureb. Insp. Fee: Elec.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.). Thesefees are based on the preffinWha information available and are only an estimate- Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 65 s.£ Remodel,Bath(<=300 sf) Suppl. PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 $645.00 IREMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee: Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: T-T Administrative Fee: 0 Work Without Permit? 0 Yes (j) No $0.00 0 Advanced Planning Fee: $0.00 Select a Non-Residential E) Tr ui,el Doetunentalion Tees: Building or Structure i Strong Motion Fee: IBSEISMICR $1.95 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 z.,. SUBTOTA.LS $2.95 $645.00 .TOTAL FEE; 5 Revises:'-'05%07%201`5 RECEIVES Or�oc� JUN 15 2015 BY �6 ADD 5 w1 11'C i�rz �t C � N6nu7(1-� LDnf-- --- ADD F-M'y Z- C" MMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION - CUPERTINO CUPERTWO APPROVED �yx.s Building Department Thi set of plans and specifications MUST be kept at the �!nv job site during coy struction. It is unlawful to make any }} JUN 15 2015 ch nges or alterations on same, or to deviate ;he,-from, mthcut approval from the Building Official. REVIEWED FOR CODE COMPLI NCE The �.ri.png of;nes pian and specifications SHALL NOT ^a _ic+ to per t or to be an approval of the violation Reviewed By; � p� f :`any s ons of any CiLy Ordinance or State Law. .-,Y ILL(OW SATE (S Py R'1. eI''� C® DOtv )P\'U� 3a • 13�