13050035CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11513 SEVEN SPRINGS LN
OWNER'S NAME: PRITI HUKKOO
OWNER'S PHONE: 4082524849
X LICENSED CONTRACTOR'S: DECLARATION
License Class F�. LLic. #
�
Contractor I N z/ g c.1.J . Date
I hereby affirm that I am licensed under the provision 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.
I have and will maintain Worker's Compensation Insurance, as proyid.g 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. 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 consequefte-of the
granting of this permit. Additionally, the applicant understands and will, comply
with all non -point source regulations per the Cupertino Municipal Cdde, Section
9.18.
Signature Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.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, I
become subject to the Worker's Compensation provisions of the Labor Code, I 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.
Signature.
Date
CONTRACTOR: WESTERN GENERAL PERMIT NO: 13050035
CONSTRUCTION INC
1192 TERILYN AVE DATE ISSUED: 05/06/2013
SAN JOSE, CA 95122 PHONE NO: (408) 887-0052
BUILDING PERMIT INFO: BLDG r ELECT F PLUMB F
MECH 17 RESIDENTIAL r– COMMERCIAL I—
JOB DESCRIPTION: BATHROOM REMODEL 60 SQFT
Sq. Ft Floor Area: I Valuation: $20000
APN Number: 36652013.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 D S FROM T CALLED INSPECTION.
Issued by: s— 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 I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
T&%��D.te: C14 A3
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
CUPERTINO
CONSTRUCTION; PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building @_cupertino.org
1_�125 3<_
❑ NEW CONSTRUCTION ❑ ADDITION
ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS i p� r� , _ 1
APN #
OWNER NAMEq.✓
PHONE
E-MA�L�
STREET ADDRESS(
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—
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRAl1'OR NAME p�
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LICENSE ER
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LICENSE TYPE
BUS. LIC # J
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COMPANY NAME , ry { ^^. ` S� r
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E-MAIL 111 o /,
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FAX
9 REET ADDRESS,
CITY STATE, ZI CA qL�
PHO De
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
A& LIC #
COMPANY NAME E-
FAX
STREET ADDRESS CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK a
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
AREA
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
V
U
ZD 01313�^
BATHROOM O KITCHEN
OTHER
REMODEL AREA REMODEL AREA
REMODEL AREA"
PORCH AREA
DECK AREA
TOTAL DECKNORCH AREA
GARAGE AREA: LJ DETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND. UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? ❑ NO
ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
E EDB
TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
Z"d O V� —
By my signature below, I certify to each of the following: I am the property owner or authorized agent o act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building Fonstruction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: t
SUPPLEMENTAL DWYMATION REQUIRED
PLAN CHECK TYPE .
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
_ 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.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
p MAJOR
❑ sAwTARY SEWER DISTRICT
submittal of Building Permit application.
❑. ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FF:F. FCTIMATOR — RTTII,DING DIVISION
;vfe, flan check
tech. Permit Mize:
Other Alech. Insp,
,ilecch. Imp. Fee:
NOTE: This estimate does not
Plumb. Plan Check Elec. Flan Check
Plumb. Permit Fee: Elec. Permit Fee:
Other Plumb Imp. Other Elea. Insp.
Plumb. htsp. Fee: Elec. Insp. Fee:
!-fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer Disi
t, School
District, etc . These fees are based on the PreffinWha information available and are only an estimate. Contact the De t or addn7 in o.
FEE ITEMS (Fee Resolution 11-053 E . 711112)
ADDRESS: 11513 Seven springs In
DATE: 05/06/2013
REVIEWED BY: larrys
MISC ITEMS
APN:
BP#: /130,560 is-
*VALUATION: 1$20,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex
USE: p
Suppl. PC Fee: Q Reg. 0 OT
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
bathroom remodel 60 sq ft.
SCOPE
;vfe, flan check
tech. Permit Mize:
Other Alech. Insp,
,ilecch. Imp. Fee:
NOTE: This estimate does not
Plumb. Plan Check Elec. Flan Check
Plumb. Permit Fee: Elec. Permit Fee:
Other Plumb Imp. Other Elea. Insp.
Plumb. htsp. Fee: Elec. Insp. Fee:
!-fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer Disi
t, School
District, etc . These fees are based on the PreffinWha information available and are only an estimate. Contact the De t or addn7 in o.
FEE ITEMS (Fee Resolution 11-053 E . 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
60 s.f. Remodel, Bath (<=300 sf)
$600.00 1REMRESBAT
Suppl. PC Fee: Q Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
h
;vfe, flan check
tech. Permit Mize:
Other Alech. Insp,
,ilecch. Imp. Fee:
NOTE: This estimate does not
Plumb. Plan Check Elec. Flan Check
Plumb. Permit Fee: Elec. Permit Fee:
Other Plumb Imp. Other Elea. Insp.
Plumb. htsp. Fee: Elec. Insp. Fee:
!-fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer Disi
t, School
District, etc . These fees are based on the PreffinWha information available and are only an estimate. Contact the De t or addn7 in o.
FEE ITEMS (Fee Resolution 11-053 E . 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
60 s.f. Remodel, Bath (<=300 sf)
$600.00 1REMRESBAT
Suppl. PC Fee: Q Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax:
Adininistrative .Fee:
®
E)
Work Without Permit? 0 Yes No
$0.00
Advanced Planning Fed:
$0.00
Select a Non -Residential
Building or Structure
0
i
Travel Documentation Fees:
Strom Motion Fee: IBSEISMICR
$2.00
Select an Administrative Item
BldR_ Stds Commission Fee: IBCBSC
$1.00
$3.001
$600.00
}
$603.00
Revised: 04/29/2013
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BUILDING DIVISION - CUPERTINO
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