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11040086 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10843 NORTHFIELD SQ CONTRACTOR:TELLY ROBBINS PERMIT NO: 11040086 CONSTRUCTION OWNER'S NAME: NAOMI SHISAIKE 659 BARTO ST DATE ISSUED:04/12/2011 ( :R'S PHONE: 4084586650 SANTA CLARA,CA 95051 PHONE NO:(408)480-1948 ❑ LICENSED CONTRACTOR'S DECLARATION J BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# �� 57 7 MECH RESIDENTIAL COMMERCIAL Contractor ;, `��Date I hereby afllm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMODEL BATHROOM(78SQFT),NON- (commencing with Section 7000)of Division 3 of the Business&Professions STRUCTURAL,INCLUDES Code and that my license is in full force and effect. MECH/ELECT/PLMBING 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 Sq.Ft Floor Area: Valuation:$14000 permit is issued. APPLICANT CERTIFICATION APN Number:31637029.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-poin so egula ions per the Cupertino Municipal Code,Section 9.18. l Issued by: Date: GP—I Z-C Signature Date G OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain 1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 255 4. 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 O agsnt: forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of wrk's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save it -!ify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address c and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 31637029. 00 DATE ISSUED. . . . . . . : 04/12/2011 RECEIPT #. . . . . . . . . BS000013167 REFERENCE ID # . . . : 11040086 SITE ADDRESS . . . . . : 10843 NORTHFIELD SQ SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : NAOMI SHISAIKE ADDRESS 10843 NORTHFIELD SQ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : TELLY ROBINS CONST CONTRACTOR . . . . . . . : TELLY ROBBINS LIC # 24204 COMPANY TELLY ROBBINS CONSTRUCTION ADDRESS . . . . . . . . . . : 659 BARTO ST CITY/STATE/ZIP . . . : SANTA CLARA, CA 95051 TELEPHONE . . . . . . . . : (408) 480-1948 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 14, 000 .00 1. 00 0 . 00 1.00 0.00 1BSEISMICR VALUATION 14, 000.00 1.40 0.00 1 .40 0.00 1REMRESBAT SQ FEET 1 . 00 570. 00 0. 00 570 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 572 .40 0 . 00 572 .40 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 572.40 --------------- TOTAL RECEIPT 572 .40 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10843 northfield sq. DATE: 04/12/2011 REVIEWED BY: bobs. APN: I BP#: "VALUATION: 1$14,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM USE: pL PERMIT TYPE: WORK sfd bathroom remodel non structural includes M E Ps. SCOPE _j NOTE. These ees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info, FEE ITEMS (f ee Resolution 09-051 Eff. 7/1,10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.f. Remodel,Bath(<=300 sf) Suppl.PC Fee: G Reg. 0 OT 0.0 hrs. $0.00 $570.00 /REMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes (D No $0.00 0 Work Without Permit? 0 Yes G No $0.00 Planning Fee: $0.00 Select a Non-Residential Building or Structure Strom Motion Fee: IBSEISMICR $1.40 Select an Administrative Item Bldg,Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $2.401 $570.00 TOTAL FEE: $572.40 Revised: 01/15/2011 O PROJECT DATA - RESIDENTIAL COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �� � (408)777-3228• FAX(408)777-3333•buiiding(ftupertino.org PROJECT ADDRE,� � T" � APN# OWNER N E-MAIL STREE gqSL1 /_/ C STATEZIp FAX tZF APP ! P �e0 E-MAIL STREETml'--- STATE, FAX(f/ % n �� ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAENT NTRAcro ❑CONTRACIORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER 11TENANT DESCRIPTION OF WORK F EXISTING USE(S): - PROPOSED USES OCCUPANCY(S): TYPE OF PARCEL CONSTRUCTION: — ) AREA: FIRE y N WUI AREA: Y N FLOOD AREA: Y N SIESMIC AREA: Y N SPRINKLERS: Existin¢ Proposed Floor Area: First Floor: s.f. s.f. Second Floor: s.f. Garages.f s.f TOTAL: s.f. s.f. Are there at least two 10 feet by 20 feet clear spaces inside the garage? Y N Is privacy protection planting required for the project? Y N Governing Codes: 2010 California Building Code(based on the 2009 International Building Code) 2010 California Residential Code(based on the 2009 International Residential Code) 2010 California Plumbing Code(based on the 2009 Uniform Plumbing Code) 2010 California Mechanical Code(based on the 2009 Uniform Mechanical Code) 2010 California Electrical Code(based on the 2009 International Electrical Code) 2010 California Energy Code 2010 California Green Building Standards Code Cupertino Municipal Code ProjectData-ResidentiaLdoc revised 03/09/11 r-r 4r Pk,-a T_ CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 950143255 (408)777-3228 -FAX(408)777-3333•building cuoertino.org OUPM)NO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN % ( C OWNER NAME I >/77J �!r f /7 l E-MAIL STREET ADDRESS V - /�, //7/ r /r STATEa ZFP`t (L / FAX CONTACT NAME L( PH E-MAIL sTREETADDRES 1,�. /� ��'2�I r_ /v` 1 (CrTY�T G"L7 r(i CJ G5 U !y FAx ❑ OWNER ❑ OWNER`Bf=ER ❑ OWNERAGENT( �ONTRACSOR ❑commACSORAGENT ❑ ARCFIITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NADff , /• � li yrs. LICENSE , / LICENSE E BUS.I.�G`)�1 COMPANY / L(� C' E-MAII. FAX 7 STREET AD S G /�J� G _CEPY,S/✓ ZIP `J n /C--) 21 ARCHITECTMNGINEERN!✓Ah LICENSE NUMBER ._ (� BUS.LIC 0 COMP ANY NAME E-MAIL — FAX --- STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK ,y r tiL waSTINGUSE PROPOSED LSE coNsm TYPE is STORIES W - EXISTG NEW FLOOR DEMO TOTAL l AREA - AREA ice__ NET AREA BATHROOM /rl KITCHIN OTHER REMODEL AREA !� REMODEL AREA` REMODEL AREA PORCH AREA DECK AREA TOTAL DECX/PORCH AREA GARAGE AREA. ❑ DETACH ❑ ATTACH A DVAU.L (G UNITS. IS A SECOND UNIT ❑YES SECOND STORY ❑YES BIUM[:ADDED? ❑NO I ADDITION? ❑NO FRE-APPLICATION ❑ YES 1F YES.PROVIDE COPY OF PLANNE[t9 NAME PLANNING APPL A ❑ NO PLANNING APPROVAL LETTER By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I h-,,'e read this application and the information I have prod ed is correct I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws relatin coon I authorize representatives of Cupertino to enter the a/bo/ve'den ed property for inspection purposes. Signature ofApplicant/Agent Date: SUPPLEMENTAL EqIFORMAnON REQUIRED New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. B1dgApp Z011.doc revised 03/16111