14060100 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21735 COLLINGSWORTH ST CONTRACTOR: 8 B PERMIT NO: 14060100
ZZXgA44P4F>D
OWNER'S NAME: ITOH TATSUO AND SEIKO �� C(�Y� 'Uh DATE ISSUED:06/16/2014
OWNER'S PHONE: 4087251334 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
REMODEL(E)66 SQ FT TO MASTER BATH TO INCLUDE
License Class
,A Lic.# oe M,E,P'S
Contractor / E le C 0 a-1�_Date
I hereby affirm that I am licensed under the provisions of C apter 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. Sq.Ft Floor Area: Valuation:$15000
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 APN Number:35617067 00 Occupancy Type:
permit is is ied�
�ICANT 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 DFRO AST CALLED INSPECTION.
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 thii it.Add*mrnW t understands and will comply Issued by: DatV +
with.all-non-point source ions per the e o Mu!Z;
-- "' RE-ROOFS:
Signature i DateAll 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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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 d
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectjuts-255 1545533- 34.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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
9 18.
Signature Date
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 1�1��
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �' \
(408) 777-3228• FAX(408)777-3333•building a()cupertino.orq \
CUPERTINO
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS L S r APN# ^�,� ) ✓ /C�
r ✓/,�.Y V
OWNER NAME PHON o 7 E-MAIL
STREET ADDRESS CITY, STATE,ZIP C y'-07%� FFAX
40C
CONTACT NAME PHONE E-MAIL l
y o o
STREET ADDRESS CITY,STATE,ZIP FAX
IJ OWNER ❑ OWNER-BUILDER El OWNER El �(,YC
OWNER AGENCONTRACTOR ONTRACTORAGENT ❑ ARCHITECT ❑ENGIN'EER ❑ DEVELOPER ❑ TENANT
CONTRACTOR N ME LICENSE NUM R LIC E TYPE BUS.LIC
COMPANY NAME E-MAIL FAX jJ
STREET ADDRESS CITY,STATE,ZIP PHONE
O
ARCHITECT/ENGINEER NAME / LICENSE NUMBER 0 BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS / CITY,STATE,ZIPPHONE
DESCRIPTION OF WORK ( ^ .A al k( �" 1/*" l
O _ �^
,--r
EXISTING USE PROPOSED USE CONSTR TYPE 1 #STORIES USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NEr AREA
BATHROOM KrrCHEN OTHER
REMODEL ARE �/J REMODEL AREA REMODEL AREA -
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
[]ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? E)NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN E]YES r-'REGEIVED$Y�y+� _, TOTt} x�ATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO ''^"z` �'�. i �y `i;. t t a'
By my signature below,I certify to each of the following: I am the property owner or authorized ag e property owner's behalf. I have read this
application and the information I have provided is ggrrep I have read the Description of Work and!Date:
ify it is accu te. I agree to comply with all applicable local
ordinances and state laws r fling constructio oriz representatives o ertino nter bov -identified p operty fo Inspection purposes.
Signature ofApplican Agent: '�
CHECKT
SUPPLEMENTAL INFORMATION REQUIRED _ ROUTING
Al� YPE ., ,SLIP
OS Ie e -i i
New SFD or Multifamily dwellings: Apply for demolition permit for [j oEI�HE counTER �k3BUILDII:GPLAIVREVIEw
existing building(s). Demolition permit is required prior to issuance of buil ng " Vit" r '•o- t, 1'£$
!0Z gEXPRESSO PLANNING PLANREVJEw
permit for new building. Wr ,
_
Commercial Bldgs: Provide a completed Hazardous Materials DisclosureO sisnpxn PUBLIC woRxs
1s e y
form if any Hazardous Materials are being used as part of this project. � �dy� j QkIREnEPT
_Copy of Planning Approval Letter o
sur Meeting with Planning prior to tto k sAl.IxnxY sEWEx DtsTlucr ,
bmittal of Permit application.
B1dgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21735 collingsworth DATE: 06/16/2014 REVIEWED BY: Mendez
APN: BP#: '`VALUATION: 1$15,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDRE
USE: PERMIT TYPE:
wORK remodel a 66 sq ft to master bath to include m e 's
SCOPE
ar'ec;r. P/ren t'dt<cck Plrun;h. Plan L:hecA,
71,ermil Fee: flim•. P, -mit J ec'
Ofhcr AIs,chP Irty, Other Plumb 7rup,
I,z-sly. 1• Numb. lush. /Ise Lae<.. h7sp,1Ie:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). 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,f' 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = s.f. Remodel,Bath(<=300 sf)
Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 $626.00 IREMRESBAT
i
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. 0 OT Fo,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
�lt:�'TTZtt_t'CtY.XZtt'c?1``c;'f:
Work Without Permit? ® Yes (E) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential E)
7rr��'��l ifr> rr}}}�a�/rxlir�r Ifees: Building or Structure 0
i
Strong Motion Fee: IBSEMMICR $1.50 Select an Administrative Item
BldgStds Commission Fee: IBCBSC $1.00
µ i` F7
750, $626.00 TOTAL FEE: $628.50
Revised: 04/01/2014
C 9
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"---#UPERTINO
''IrfinO D(m0artment
JUN 6 2014
ODF COMPLIANCE
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com ",!0(4104T DEPARTMENT
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Cl ib -510N -CUPERTINO
PPROVED
This�of pians and specifications MUST be kept at
job site durilig construction. It is unlawful to make
Changes or alterations on same, or to deviate
'E
t at
make
te
therefrom, without approval from the Building off cial. r
The Stamping of this plan and specifications'SHALL NOT (Q 7
be held to Permit or to be an aggmazf��ion 0o tab e
f
any r y ity Ordinance or State Law.
E.
a Ire ',"-Zil:AwiT NO. 77�,
4L, � IP U) 7"Z � A OFFICE (1';60PY