12080332CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10175 AVOCADO PL I CONT TOR- Bft—P6-BE I PERMIT NO: 12080332
OWNER'S NAME:
1 , 1 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
License Class 79L � I Lic. #
Contractor ��C� (' 7 Date
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:
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 die 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 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 —44��
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and wil I 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 die 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 al I 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.
JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL
BATRHOOM REMODEL 120 SQ FT, RELOCATE FURNACE
TO
GARAGE / L h,-17at.li iN
Sq. Ft Floor Area: I Valuation: $77000
APN Number: 36909010.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: ✓� /-� 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. 1 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 25505.2W3 nd 25534.
Owner or authorized agent: .
0A
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature Date
Fm_�
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10175 AVOCADO PL
DATE: 08/31/2012
REVIEWED BY: MENDEZ
APN:
BP#:
'VALUATION:
1$77,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
BATHROOM REMODEL 120 SQ FT RELOCATE FURNACE TO GARAGE
SCOPE
Mech. Plan Check 0.0 1 hrs $0.00
Plumb. Flux, Check
Elec. Plan Check
Mech. Permit Fee: IMPERMIT
Numb. Permit Fee:
Dec. Permit Fee.
Other Mech. Insp. 0.0 hrs $45.00
Other Plumb Insp.Li
Usher Elec. Insp.
Alech. Insp. rec:
Phanb. hisp. re a:
Cleo. Insp. ree:
NOTE: This estimate does not inchidefees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District,eta). These fees are based on the Preliminary information available and are only an estimate- Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
120 s.f. Remodel, Bath (<=300 sf)
$600.00 IREMRESBAT
Suppl. PC Fee: (D Reg. Q OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
F__17 # Mechanical
$133.00 IWR=<100 Fumace, Forced -Air
Permit Fee:
$0.00
Suppl. Insp. Fee-.0 Reg. Q OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
Conso-nelion Tax:
Administrative Fee: 1ADMIN
$42.00
E)
Work Without Permit? O Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential 0
Building or Structure 0
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IBSEISMICR
$7.70
Select an Administrative Item
Bldp, Stds Commission Fee: IBCBSC
1 $4.00
SUBTOTALS:
1 $143.701
$733.0011
TOTAL FEE:
1 $876.70
Revised: 07/01 /2012