13020142I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 21820 HERMOSA AVE
CONTRACTOW 4;99 :�O BE j PERMIT NO: 13020142
OWNER'S NAME: MAGDALENA SOLORIO
OWNER'S PHONE: T in CI C 7
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lie. #
Contractor 57111a �Di7Sh1& ,7-n Date D 2?72 - -13
1 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..
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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.
1 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.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct..l 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 Deep 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 applicant understands and will comply
with all non -point sour dyttns per the Cupertino Municipal Code, Section
9. 18. /j
Signature Date 02 2 -13
❑ . OWNER-BUILDER.DECLARATION
1 hereby a. irm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: .
1, as owner of the properly, 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
construct the project (See.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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, 1
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
forthwith comply with such provisions or this permit shall be deemed revoked.
. APPLICANT CERTIFICATION
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
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 applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. .
1 V,-A I DATE ISSUED: 02/27/201.3
( ' I PHONE NO:
JOB DESCRIPTION: RESIDENTIALD COMMERCIAL
RELOCATE KITCHEN 110 SQ FT ADD 2 SKYLIGHTS,
BATHROOM REMODEL OF 118 SQ FT, WATER HEATER,
A/C
Sq. Ft Floor Area: I Valuation: $24000
APN Number: 35716055.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS OF PERMIT ISSUANCE OR
180 DAY OM LAST CALLED IN CTION.
Issued by: Date
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER,
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should 1 store or handle hazardous
material. Additionally, should 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sectiogs!1tM 25,533, and 25534.
Owner or authorized agent: i lwi Date:42:2
CONSTRUCTION LENDING AGENCY
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.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature Date
IM4 CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21820 HERMOSA
DATE: 02/27/2013
REVIEWED BY: 2
APN:
BP#: l�0 v�O��O�
*VALUATION: 40
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
RELOCATE KITCHEN 110 SQ FT ADD 2 SKYLIGHTS BATHROOM REMODEL OF 118 SQ FT
SCOPE
WATER HEATER, A/C
Mech. Plan Check 0.0 hrs $0.00
Plumb. Plan Check 0.0 hrs $0.00
Elec. Plan Cheek
Mech. Permit Fee: IMPERMIT
Plumb. Permit Fee: IPPERMIT
Elec. Permit Fee.
Other Mech. Insp. 0.0 hrs $45.00
Other Plumb Insp. 0.0 hrs $45.00
01her E/ec. Insp.
Mech. Insp. Fee:
Plumb. Insp. Fee.
Elec, Insp..Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the preliminary information available and are only an estimate Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F-110-1 s.f.
$600.00
Remodel, Kitchen (<=300 sf)
IREMRESBAT
Suppl. PC Fee: Q Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
F 1-181s.f.
$600.00
Remodel, Bath (<=300 sf)
1 IREMRESBAT
Permit Fee:
$0.00
Suppl. Insp..Fee-0 Reg. 0 OT
0.0
hrs
$0.00
= # Mechanical
$133.00 IWR=<loo Furnace, Forced -Air
PME Unit Fee:
$0.00
PME Permit Fee:
$90.00
0 #
$27.00
Plumbing
IPRWHEATR Water Heater
Construction Tar:
Administrative Fee: 1ADMIN
$42.00
1-1 #
$67.00
Plumbing
IPGASRES Piping, Gas <=4 Outlets
Work Without Permit? 0 Yes (E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IBSEISMICR
9�I X.50
Select an Administrative Item.'
Blda Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$178.50
$1,427.00J
TOTAL FEE:
$1,605.50
Revised: 01 /01 /2013