13120192 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6401 BOLLINGER RD CONTRACTO' PERMIT NO:13120192
/G�LyLOQ� i
OWNER'S NAME: MICHAEL BOHN ET AL DATE ISSUED: 12/23/2013
OWNER'S PHONE: PHONE NO:
L] LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E]
RECONFIGURE BEDROOM CLOSETS TO CREATE(N)
License Class Lie.# HALL
pp y�K
Contractor f� l�_ BI(f`►ym y
Date�� 3 BATH(60 S.F.)
I 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.
( F 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:$3750
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:36920027 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 WITHIN 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 DAYS +R SPECTION.
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 Issued b ate: Z Z3
with all non-point source regulations per the Cupertino Municipal Code,Section
918.
n RE-ROOFS:
Signaturea : Date t/23 zDI 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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. I 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,Sectiogs 25595,2 33,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: At. Af Date:L2:25
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 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
918.
Signature Date'
I ,
CONSTRUCTION PERMIT APPLICATION n ,�
.COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION \ V
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777+3228•FAX(408)777-3333•building
Ca7cupertino.org \
CUPERTIINC
❑NEW CONSTRUCTION ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS: 7APN
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OWNERNAME _ I - PHONE Z E-MA Q I iCE Ij'r�rFt.;,rli,I:hK.ne..{
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STREET ADDRESS - C Y, STATE,ZIP FAX
�r4�,�� HIS/s
CONTACT NAME nn PHONE E-MAIL
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STREET ADDRESS - CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUnDER - ❑ OWNER AGENT dCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMEC'c, hs 2 LICENS NUMBER LICENSE TYPE BUS.LIC#
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COMPANY NAME E MAIL
n FAX
( r Crr.reAl r 9 4ko. Cam 3 -66--6 7 1
STREET ADDRESSSTATE,ZIP P ONE
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ARCHITECT/ENGINEER NAME _ _ 'LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORKe� G 1 e1�I f LM VQ - r Z
Z : S I er � me net", tm ll i SI t'j +
4'(112 PA161 41,va e ec r'Ced Or tv / 14
EXISTING USE PROPOSED USE CONSTR TYPE #SO S
USE TYPE OCC. SQ.FT. VALUATION($)
EMSTG. NEW FLOOR - DEMO- TOTAL O
AREA - AREA AREA - NET AREA 3 3760 "¢
BATHROOM KITCHEN OTHER
REMODEL AREA SGt' REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ODETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNTT ❑YES SECOND STORY ❑YES
BEINGADDED? ONO ADDITION? ONO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES - -- .. TON:
PLANNING
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO U
By my signature below,I certify to each of the following: I am the property owner or authorized age act n the pro rty 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 cora . I agree to comply with all applicable local
ordinances and state laws relating to'b 'din construction. I authorize representatives of Cupertino to enter the e-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 12— -23- 260
SUPPLEMENTAL 0R1vIATIONRYQUIRED
_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:
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 6401 BOLLINGER RD DATE: 12/23/2013 REVIEWED BY: MELISSA
its APN: 369 20 027 BP#: "VALUATION: 1$3,750
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM
USE: p PERMIT TYPE:
WORK RECONFIGURE BEDROOM CLOSETS TO CREATE N HALL BATH 60 S.F.
SCOPE
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IN 0111i'll"
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Lli c:h. Phan Check 1 .1Plutrrb.Plan Check Dec-.Plan Check
:L1e7Permit Fee: Plumb.Permit Fee: Elec. Permit Tee:
F".
.1fech.Insp. 01her Plumb Intl. Other Elee.Insp. Li. Insp.Fee: Plumb. I11sp.Fee: Elec,Insp. Fee:
NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Theseees are based on the prelimina information available and are only an estimate Contact the De t or addn'1 info.
FEE ITEMS(Fee Resolution 11-053 E . 7f/ 11/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = s.£ Remodel,Other
Suppl.PC Fee: (E) Reg. 0 OT 0.0 1 hrs $0.00 $418.00 IREMRESOTH
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee-.0 Reg. ®OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
(.7ont-fiction Tax: _
Adin inistrative.Fee:
Work Without Permit? 0 Yes (E) No $0.00 L E)
Advanced Planning Fee: $0.00 Select a Non-Residential
Building or Structure
Travel Documentation Fees: i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
IN
y $1.50 $418.00 $419.50
Revised: 10/01/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 6 1-�v l 6 p f�n4Pr k.a PERMIT# 3 t 2O I Z—
OWNER'S NAME: n , A-1 PHONE# '
GENERAL CONTRACTOR: CiPrA, k9covdt-kn4i BUSINESS LICENSE#..
ADDRESS: , CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to haves City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WJiL,BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SU CONTRACTORS.HAVE OBTAINED";A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: _2 "2� 3
ignature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME ''BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing Ln
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing zz
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
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This sat of plan and specificatlons N9•U T by kep. t t e
job site during onstruction. It is unl eN UI tO rria.kra c ny e
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changes s r alterations on same, dovlaie e4yed 8 �t4rF�L,fAP
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1 � therefrom,without approval from the Building Gftialal. � ---_
The stampingthis plana
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be held to p roval of the violation o
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dinance or State Law.
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