12030163 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10057 IMPERIAL AVE CONTRACTOR:SURJIT KAUR-GREWAL PERMIT NO:12030163
OWNER'S NAME: SURJITKAUR-GREWAL 10057 IMPERIAL AVE DATE ISSUED:05/24/2012
OWNER'S PHONE: 4086079700 CUPERTINO,CA 95014-5904 PHONE NO:
0 LICENSED CONTRACTOR'S DECLARATIONr
BUILDING PERMIT INFO: BLDG r_ ELECT I— PLUMB
License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL F
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RESTORE 1000 SQ FT NON CONFORMING RESIDENTIAL
(commencing with Section 7000)of Division 3 of the Business&Professions UNIT
Code and that my license is in full force and effect TO OCCUPANCE B-OFFICE UNIT. CONSTRUCT NEW 6 FT
AND 3 FT FENCE ALONG PROPERTY LINE AT PARKING
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
permit is issued. Sq.Ft Floor Area: Valuation:$0
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:35717014.00 Occupancy Type:
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California, If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner��orized an forthwith comply with such provisions or this permit shall be deemed revoked.
V
Date:
APPLICANT CERTIFICATION /CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of wrk!s
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(See.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-M' urce regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9,18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
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CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10051 Imperial Ave DATE: 03/30/2012 REVIEWED BY: Sean
APN: 357-17-014 BP#: j 'VALUATION:
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1 B TI
USE: PERMIT TYPE:
WORK Convert 1000 sq ft nonconforming residential unit to occu ance B-Office unit. Construct 21 §_q ft
SCOPE I covered porch, 56 sq ft bathroom remodel, remove and replace stucco at front elevation, construct nevh
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
B(Tenant Improvements) II-B,II1-B,IV,V-B 0 $0.00 $0.00
TOTALS: 0 $0.00 $0.00
MECH,HOUR Y 0 Yes 0 No PLUMB,HOURLY 0 V 'Nu ELEC,HOURLY 0 Yes ONO
fc ch, F't m('heck ,< 1' _'('heck f'Icrc,:'Iran t.;hc>el:
'ee:
C)ttr,.a ;Wech, lasy'?. 03'her I'I,j"'2b 1rasp. Ll L- Oilier~Elec.h7q),
NOTE.This estimate does not include fees due to other Departments(i a Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta . These ees are based on the relimina information available and are onl an estimate. Contact the De t or addn 7 in o.
FEE ITEMS(Fee Resolution 11-053 off 7I1111� FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes 0 No $0.00 Select a Misc Bldg/Structure
Suppl.PC Fee: (F) Reg. 0 OT0,0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp.Fee-.0 Reg. 0 OT El hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
(,'o?.°t uc=tion Tax:
Work Without Permit? 0 Yes No $0.00 E)
Advanced Planning Fee: $0.00 hours Plan Check,Hourly E)
1110vel Docutnentavion Fees: $130.00 ISTPLNCK �
Strong Motion Fee: $0.00 Select an Administrative It
e
Bldg Stds Commission Fee: $0.00
UUTOTALs: $0.00 $130.001 TOTAL FEE:-, $130.00
Revised: 1/19/2012