12070172 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10630 GASCOIGNE DR CONTRACTOR:JAHAN CONSTRUCTION PERMIT NO:12070172
OWNER'S NAME: TSURI-ETZIONI AMIR AND AVITAL 200 BURNETT AVE STE 71 DATE ISSUED:02/22/2013
OWNER'S PHONE: 4083187142 MORGAN HILL,CA 95037 PHONE NO:(408)782-3102
Ef LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALS
License Class Lic.# Zp I 3 CONSTRUCT A MASTER BEDROOM AND BATH
J ADDITION(488
Contractor f}j A n/ 0 46 Date �, I5�l 3 SQ FT); CONSTRUCT PLAYROOM AND FAMILY ROOM
I hereby affirm that I am licensed under the provisions of Chapter 9 ADDITIONS(554 SQ FT); KITCHEN REMODEL(80 SQ
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that m license is in full force and effect.
y -i�v1�1� 1 - i2.evts� ��- t�. �� pt�ti
I hereby affirm under penalty of perjury one of the following two declarations: 1 SS t=> 0 i C-- S•15°4
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:$85000
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:37522022.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT E S IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 18 A S 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 DAYS O 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 �7
Issued by: Date:
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.
RE-ROOFS:
Signatureasp nti= Date 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 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. 1 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,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date:
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
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10630 GASCOIGNE DR CONTRACTOR:JAHAN CONSTRUCTION PERMITNO:12070172
OWNER'S NAME: TSURI-ETZIONI AMIR AND AVITAL 200 BLIRNETT AVE STE 71 DATE ISSUED:02/22/2013
OWNER'S PHONE: 4083187142 MORGAN HILL,CA 95037 PHONE NO:(408)782-3102
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALS
# / „ l CONSTRUCT A MASTER BEDROOM AND BATH
License Class_Lic.
ADDITION(488
Contractor SQ FT); CONSTRUCT PLAYROOM AND FAMILY ROOM .-
I hereby.affirm.that.I am licensed under the provisions of Chapter 9 ADDITIONS(554 SQ FT);KITCHEN REMODEL(80 SQ
(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:$85000
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:37522022.00 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 WITION 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.'2�,'Y�S FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 1 1. k;
costs,and expenses which may accrue against said City in consequence of the -s •j -
granting of this permit. Additionally,the applicant understands and will comply Issued by 1':f Date
with all non-point source regulations per the Cupertino Municipal Code,Section
fi
9.18.
RE-ROOFS:
Signature r;� _ Date? 2- All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without fust obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION Date:
Signature of Applicant:
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 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
1,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 25534.1 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
1 have,and'will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sections 25505,25533,and 25534.
e
Section 3700 of ,the Labor Code,for the performance of the work for which this Owner or authorized agent: d. ..�e�a Date:'17
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 CONSTRUCTION LENDING 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
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
p y p p 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 buildirig construction,and hereby authorize representatives of this city to enter
upon the above mentioned propertyfor 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
CITY OF CUPERTINO r
FEE ESTIMATOR-BUILDING DIVISION kv
ADDRESS. 10630 Gascoigne Dr DATE: 07/25/2012 REVIEWED BY: suew
APN: BP#: 12070172 *VALUATION: 1$85,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY 2nd Unit? Yes No PENTAMATION
USE: SFD or Duplex OTC? 0 Yes No PERMIT TYPE: 1 R3SFDADD
WORK Addition Master Bedroom & Bath 488 s ft Kitchen remodel 80 sq ft
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
R-3 (Custom) II-B,111-B,IV,V-B 488 $1,512.00 IADDPLCK $1,230.00 IADDINSP
TOTALS: 488 $1,512.00 $1,230.00
MECH,HOURLY 0 Yes O No PLUMB,HOURLY Q Yes (j) No ELEC,HOURLY 0 Yes Q No
E I J
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 prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $1,512.00 80 s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: 0 Reg. Q OT 0.0hrs $0.00 $600.00 1REMRESKIT
e
PME Plan Check: $0.00
Permit Fee: $1,230.00
Suppl. Insp. Fee-0 Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Work Without Permit? 0 Yes Q No $0.00 )
Advanced Planning Fee: IPLLONGR $63.44 Select a Non-Residential O
Building or Structure O
A
Strong Motion Fee: IBSEISMICR $8.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $4.00
SUBTOTALS: $2,817.94 $600.00 TOTAL FEE: 1 $3,417.94
Revised: 07/01/2012