14080239 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21607 FLINTSHIRE ST CONTRACTOR-+4P--TQ BE PERMIT NO: 14080239
O�tlED
OWNER'S NAME: JIAO YUAN AND DUAN TONG u,5/r7 DATE ISSUED:08/25/2014
OWNER'S PHONE: 4083329912 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
q KITCHEN REMODEL 300 SQ FT,ADD 1 SKYLIGHT TO
License Class �� Lic.# l d O Cy HALLWAY,RELOCATE WATER HEATER AND FURNACE
a6151/yG Lai fQ/eG%/4'�� O/� IN
Contractot �� Date �,5 ATTIC
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.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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
CAperformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$45000
1 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:35620054.00 Occupancy Type:
rmit 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. 1 agree to
tr comply with all city and county ordinances and state laws relating WITHIN 180 D IT 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 FR LAST CA LED IN PE TI N.
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 by: r Date:
with all non-point source regula'ons per the Cuperti o Municipal Code,Section
9.18.
�J� R - OFS:
Signature e/ �6 Dated All roofs shall be inspected prior to any rooting material being installed. If a roof is
installed without first obtaining an inspection,1 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
1,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)
1,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,Sections 5Q5,25533,and34.
Section 3700 of the Labor Code,for the performance of the work for which this y Q'
Owner or authorized age ` /I/ lG Date: x
permit is issued.
1 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,[ 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
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
CONSTRUCTIONR I P I
PERMIT T AP L CATION u�
12 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333 •building aacupertino.orq
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/Tl ❑ REVISION/DEFERRED ORIGINAL
I p PERM
IT#
PROJECT ADDRESS 2-t
/C IYk Jt APN# '55t 60
OWNER NAME j PHONE /T ��.� E-MAIL
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME --- LICENSE NUMBER LICENSE TYPE BUS.LIC#
[eLiu 0
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK14, fxl) i
0— .
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCH OTHER
REMODEL AREA RP,MO REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA. DETACH
❑ATTACH
4 DWELLING UNITS IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEINGADDED? ❑NO ADDITION" ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDGAN [IYES RECEIVED BY: TOTAL LUATION:
PLANNING APPLti ❑NO PLANNING APPROVAL LETTER EICHLER HOME" ❑NO
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(Ne-7erad 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 constr tion. I authori e representatives Of Cupertino to enter the above-identified p/ro for inspection purposes.
Signature of Applicant/Agent: Date: )-
SUPPLEMENT RMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifal dwellings: Apply for demolition permit for OVER-THE-COUNTER PLANREVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS PLANNING PLAN REVIEW
_Commercial BIdgs: 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 ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp_2011.doe revised 06/21111
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 21607 flintshire st DATE: 08/25/2014 REVIEWED BY: Mendez
APN: BP#: �0a3'9 7, "VALUATION: 1$45,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREIVI
USE: PERMIT TYPE:
WORK kitchen remodel 300 sq ft add 1 skylight to hallway, relocate water heater and furnace in attic
SCOPE
Mech.Plan Check0.0 hrs $0.00
Mech.Permit Fee: I MPERMIT
Other Mech.Insp. 0.0 �rs $48.00
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 Elf 7%1%13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 DKI s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: (j) Reg. Q OT0,0 hrs $0.00 $645.00 IREMRESKIT
PME Plan Check: $0.00 = # Skylight
Permit Fee: $0.00 $431.00 ISKYL<IOSF <= 10 s.f.
Suppl. Insp. Fee:G Reg. 0 OT 1 0.0 1 hrs $0.001= # Mechanical
PME Unit Fee: $0.00 $143.00 IMFR=<100 Furnace, Forced-Air
PME Permit Fee: $48.00
Administrative Fee: IADMIN $45.00 0
Work Without Permit? Q Yes No $0.00
Advanced Planning Pee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $5.85 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $2.00
SUBTOTALS: 1 $148.851$1,219.00 TOTAL FEE: $1 ,367.85
Revised: 07/10/2014