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15070012 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11�8 ELMSFORD DR CONTRACTI ��+� PERn1IT NO: 15070012 QPr�'R)�S lti 1�6ti�R �i� O«'NER'S NAn4E: GHISELLI DAVID AND RUTH A DATE ISSUED:07/02/2015 OWNER'S PHONE: 4082554572 PHONE NO: LICENSED CONTRACTOR'S DECL.ARATION JOB DESCRIPTION:RESIDENTIAL � C0114MERCIAL � �1 RELOCATE/REMODEL(E)MASTER BATH(101 S.F.) License Class Lic.# � �dC�� REPLACE 3(E) WINDOWS& 2(E)DOORS. ADD(N)ATTIC �+ � J� J /� ^i� �S/ h�' FAN,UPGRADE ELECTRICAL LIGHT FIXTURES (21), Contractor�f � �S (,V �1 Date J� I hereby affrm that I am licen d under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 oT 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 1rca: 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:36209013.00 Occupancy T��pe: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is pERMIT EXPIRES IF WO IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating wITHIl�1 180 D ,RMIT 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 ALLED INSPEC ION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, � costs,and expenses which may accrue against said City in consequence of t e Da : � 2 ` eranting of this permit. Additi ally,the applicant understands and wil with all non-poin source re� at n er the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature � Date � �� 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. ❑ OR'NER-BL?ILDER 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[he work,and[he 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 lIealth&Safety Code,Sections 25505,25533,and 25534. I will I hcreby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Ilcahh&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 Arca 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,Secti 2550 5 3 �and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Ow�ner 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 Califomia. If,afrer making this ceRificate 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 pem�it shall be deemed revoked. ti'ork'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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCI�ITECT'S DECL.AR4TION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. �ranting 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 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO �408) 777-3228� FAX (408) 777-3333 •buildingCa�cupertino.orq �� '�J 6 � / � � � ❑NEW CONSTRUCTTON ❑ ADDTTION ALTERATTON/Tf ❑ REVTSiON/DEFERRED ORiGTNAL PERMTT� PROJECT ADDRESS�� L 1' �/ � `�� APN t! ��^ '_' C,� � O I �� `� j.� OWNER NAME ��,�� S�� PHONE r� E-MATL STREETADDRESS/�� 1�5��'��'� CITY, STATE,ZIP GU�� 1 FAX CONT:4CT NAME L��9'�Y7 �O�r�C PHONE��ql�.�`�`f„ ``� � `S��LPD`O`-��'� ir•_ ` •� STREE"C ADDRESS CI7Y,STATE, Z1P FAX � 5 i c� Wt��va �G L 'Co� ��3"�— ❑ (1WNER ❑ nWNHR-BUILllER ❑ nWNER AGENT ❑ CnNTR,1CTOR ❑CnN'IRACTnR AGENT 1RCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TEN�NT CONTRACTOR NAME � � j� i LICENSE A`U?vfBER LICENSE TYPE BUS.LIC# �G�.r r f O S V�� COMPANY NAME E-MATL FAX STREET ADDRE55 CITY,STATE,ZIP PHONE ARCHIT`TCT/ENGINEER NAM14E LfCFNSE NU�IBER C.--3 � ( � � BUS.LIC� ' \� '�� 1 COMPANYNAh1E � � � E-MAIL L'�� C'_�I� . �O\► F�Ak �� S'1'REET ADDRESS CTTY,STATE,ZiP PHON S o t�l S�ov.� `� �5 �"�o s C�s o 3'z- -o �G� DEsc�moN oF wox�c D o � �6 S'CG�cz_$��o`M �s-�'�F�— ct-o5�'� . N' 1M�C��'R-��7R'M . �� 'tz�{ �7 00'C�- S�5 1+�\• RG�G�- S�E d ��.L R-`C��c ��o u t'��s_ c� — , — s�K-r�C� �1 � � Sw��G -�� P EX15T1NG USE PROPOSEll L'SE COtiSTit TYPE i!STORIES b� �� p,_,� USE TYPE OCC. SQ.FT. VALUATION($) r--� v EX15TG NEW FLOOR DEMO TOTAL � AREA ARE,4 ARFA NET AREA 1 B.4THROOM KITCHEN OTf�R REMODELAREA �Qf� REMODELAREA REMODECAREA �� PnRCH AREA DECK.1RE,4 "inTALDECK/PCIRCH AREA GARAGE,IRE,4: UETACH �A'tTACH k U\\'El.l_ING Uhf1�S. 1S a SECOtill lNl'f �YES SECONll S"1'ORY' ❑YES BETTVGnUllEll? �C"1N0 AllDITiON? NO o` YRE-APVLICAT'(ON ❑Y6S iF YES,PROVIIIE COPY OF i5 THE BLllG RECEI TOT�VALU.4TION: � YLANNING?3PL# �NO PLAriNLNG.4PPROVALL�7'f�R EICHLERHO -. S'r' QQ� �� 1 By my signature below,I certify to each of the fotlowin�: I am the property own r autho aQent to ct on the prope o��mer's behalf I ha ead this application and die information I have provi d is co ec[_ I have read the Descriplion of Work and verify it is accurate. gree to comply wi[h all appiicable local ordinances and state lav��s re(ating to n. I authorize representati��es of Cuper[ino to ent r the abov dentified propeRy for inspection purposes. Signature of ApplicandA�ent: ; Date: SUPPLEMENTAL. RIVLA ION REQUIRED PLAN CHECK TYPE ROUTING SLIP N��1�SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COLmTER ❑ BUILDLVGPL.ANRE�7ER' existing building(s). Demolition pennit is required prior to issuance of buildiiig permit for new building. ❑ �r�ss ❑ PI.ANNINGPL,.4NRE�'IEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PLBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ �ARGE ❑ FIRE UEI'T Copy of Planning Approval Letter or Meeting��ith Planning prior to ❑ �L��oe ❑ SA'�1T_1RY SE�\'ER DISTRICT submittal of Building Permit application. ❑ ENVTR0�IMF.�T4L HEAI.TA Bld�4pp_2011.doc revised 06/21/I1 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 1158 ELSFORD DR DATE: 07/01/2015 REVIEWED BY: MELISSA � APN: 362 09 013 BP#: �j `VALUATION: $15,000 vPER111T TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 R3SFDRE� wo� RELOCATE/REMODEL E MASTER BATH 101 S.F. . REPLACE 3 E WINDOWS. ADD N ATTIC SCOPE FAN. UPGRADE ELECTRICAL LIGHT FIXTURES (21), OUTLETS (9) & SWITCHES (10). REPLACE � Mech.Plan Check 0.0 hrs $0.00 Elec. Plan Check 0.0 hrs $0.00 Mech.Permit Fee: IMPERMIT Elec.Permit Fee: IEPERMIT Other Mech. Insp. 0.0 hrs $48.00 . . . , Other Elec.Insp. 0.0 hrs $48.00 NOTE: Tlris estimate does not include fees due to ot/rer Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,Schoo[ District, etc. . These ees are based on tlre reliminary in orniation available and are only an estin:at� Contact the De t or add�:'l i�: o. FEE ITEMS (Fee Resolution 11-0�3 E�'� '%1��13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 101 s.f. Remodel, Bath(<=300 s� Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $645.00 �n��tn�'SBAT PME Plan Check: $0.00 5 # Window/ Sliding Glass Door Permit Fee: $0.00 $431.00 1 wINREP Replacement Suppl. Insp. Fee:Q Reg. Q OT p.p hrs $0.00 � # Mechanical PME Unit Fee: $0.00 $25.00 IBRE��vENF Ventilation Fan PME Permit Fee: $96.00 �9 # Electrical $48.00 �BREMRECEP Recep/Switch/Outlets Administrative Fee: �ADA11N $45.00 21 # Electrical � Work Without Permit? � Yes � No $0.00 $78.00 IBREMFIXT Fixtures, Lighting � Advanced Pla�lni»�Fee: $0.00 Select a Non-Residential � Travel Documentation Fee: ITRAVDOC $48.00 Building or Structure � i Strona Motion Fee: IBSEISMICR $1.95 Select an Administrative Item Bld� Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $191 .95 $1 ,227.00 TOTAL FEE: $1 ,418.95 Revised: 05/07/2015