11110022 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 209001 IOMESTEAD RD CONTRACTOR:MONTEREY PERMIT NO: 11110022
CONSTRUCTION COMPANY
OWNER'SNAME: PROMETHEUS SHM(1,NTEREV-S LINAS II\\'1'SI'EA DA'Z'E ISSUED: 11/042011
.R'S PHONE: 6509313400 SA W NAS,CA 93908 P1[ONE NO:(831)601-2659
IA CENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT I— PLUMB 17
License Class Lie.b
IF
NIECII r RESIDENTIAL r COMMERCIAL r
Contmcto Date j (L
1 hereby affirm that I a icensed under the provisions of Chapter JOB DLSCRI PTION: DLDMUNITCr-REMODEL KITCHEN(50SQFT)&
(commencing with Section 7000)of Division 3 of the Business&Professions WASI IER/DRYER I100KUP&ADD NI?W A/C UNIT
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insurc for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for(he
performance of the work for which(his permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq. Ft Floor Area: Valuation:$20000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APS Nu ober:32609065.00 Occupancy Type:
APPLICANT CI?R'I'IFICA'1'ION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit, Additionally,the applicant undcrsum(ls and will Comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9'18Issued by: Date//�i y/Lj
r z
Signatur " Date-yal
OWNER-RU 111)ER DECLARATION HF:ROOFS:
All roofs shall he inspected prior to any rooling material beug installed If a roof is
1 hereby affirm that 1 am exempt from the Conlrndnr's License Low for one of ins(:licd withom first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,as owner of the property,or my employees with wages us their sole compensation,
will do the work,and the structure is not intended or ollered for sale(Sec.7044, SignuWrc of Applic ni: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: I IAZARDOI IS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 hove rend the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of(he I abor Code,for the California Health&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued, compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(n)should [more or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
rautmvinan(e as defined by(he Bay Arca Air Quality Dlanagement District I will
permit is issued, mahonin compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,I shall I lralth&Safely Code, etions 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certilicnte of exemption,I Own t
become subject to the Worker's Compensation provisions ol'the Labor Code,I must DIt te:.�
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGF,N'CV
APPLICANT crwr FIC,\'I'ION I hereby affirm(hat(here is a construction lending agency for the performance of work's
I certify that I have mad this application and state that the above information is for whidn this permit is issued(Sec.3097,Civ C.)
correct.I agree to complywith all city and county ordinances and state laws relating Lendo's Name
to building construction,and hereby authorize representol Ives of this city to enter
upon the above mentioned property for inspection purposes.We)agree to save Lendo's Address
nify,and keep harmless the City of Cupertino against liabilitics,judgments,
and expenses which may scenic against said City in consequence of the ARCHITECT'S DECLARATION
withof this permit.Additionally,Ilse applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licelowd 1'rolessiunal
Signature Dale
11/03/2011 15: 31 (FAX) P. 002/005
CONSTRUCTION PERMIT APPLICATION
• COMMUNITY DEVELOPMENT.DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
.CU PER71N0 (408)777-3228• FAX(408)777.3333 • hulldlnCla.CLIDerino.om
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI -❑ REVISION/DEFERRED ORIGINAL PERMIT g
PRO)ECTADDRCSS L
AYN I-20 QQ rC] &C1,4- r5 0 Cli-
OWNER NAME PHONE EIL
m-� 4�JS \22aR -S-Fr-..1'e SO GSt-3�1V0
^STMTDD
ARESS Gy CITY, STATE,ZIP
RO� rU� FAX
CONTACT NAME PHONE E-_• IL
'b
STREETy AD�D�RESS CITY,STATE, ZIP: FA%
OwNalt ❑ OwNm-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT 0 ARCHmECT 0 CNGERaR 0 DEVELOPER 0 TENANT
rONTRACOR NAME�i LICENSF:NUMBER LICENs YTE aus.LICK
4�iY, �
COMPANY NAME n-MAIL FAX Cti3��
IYIU+VYP1 �t,'jA\ C��-'.LM -\-hcJ.��C' mr C.pr�S-1-t uc,•>r: ti, -, bS -'1S_, o
STREET ADDRESS CITY,STATE,ZII'
�d� 1-'11Ua�Yt'l - S / ' Gni PHONE C`d3+� 1
ARCHITECT/ENGINEER NAME LICENSENUMAER BUS.LICA
COMPANY NAME - E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP
PHONE
DESCRIPTION OP WORK
CA � ?_C�,OC�)C>.`�
EXISTING 0.5E PROPosan USE CONSI'RTYTB, NSTORTR. ', i ��� ��)tT ll�al,jR�'41111 AN 'Ir 9l�r Lm lV'1 -- .
YlrlK-r-Ant.
11'a;111.11 11
1y1`dI 'iu�^,.{i -{..tl:a::
e%6TG NEW FLOOR. DN.0 r1I ..
•
TOTAL
T '_pr;t I . %
AREA
- - _
AREA AREA AREA BETA HL•A i,I I'.I �! f 1 R 1111 ,.1'.
HATHROOM Rll'CHNI OTHER �tfi4 �1�1 4lJ! 11 IhL �bllll'(I If;' Ii
RIMODELAREA _RPIdODELAREA RIMODELAREA AC�)
PORCH ARFA
DETACH AREA TOTAL DECKIPORCHAREA OARAGEAREA: y { 1 I itll� li�l !i'
1t
(
❑ATTACII
rpwCLIINO UNITS: INASECOMUNIT YFS RCCUNn TI ORY �YaN 111 1I 11 1 11 lR1 (II I i1 fAAt y[t{II it 1 S ..
aIINGAaOCp1 NO ADpIT1aNr r NO 1 1111 �` 114 II r1114VI
1 P {
.W tk J �IArJn,}hY7 �IO'18L.t.r,l
PRR�MPLKATgN ❑ Yes PYCS,PNOVWacWYOY PIANNSR•s NMN: �1 �aillwav, G ;i'je 11�71J I,r,i Y 1tl r -
�NNfµ� lk,:i,1 ]y4ald llt011; \RO 112L 1 LUATION
PLANNI APPI, No PIANNIM FRWAL erns 111r� 111�I���a� •I ffh Nt;ili it Ml�ltl il ���!�f Fal S
By my signature below,I certify ID each of the following: I am the property owner or authorized agent to act on the proper) owners behalf. I have read this
application and the information I huve InyA Ed Is correct. I have read the Clescritaion of Work and verify it is accurate. I a Bell to comply with all applicable local
ordinances and slate laws relating t �tg (dI g construction. I authorize lommentatives of Cupertino to enter the above�denl Red properly for inspection purposes.
Signature of Applicant/Agent: Dmc -/��/
(SUPPLEMENTAL INFORMATION REQUIRED Pu Ir Ir t 1 R 1 11 1 -
Q to : N41 n KT{yIPelN�yl lar 1 Inf_ ' aolrrlNc SLIP r
_New SFDlIor Muhifarnily dwellings: Apply for demolition permit for
existin buildih 1 d Yrli miiwtcou Tnn12t liuiunwc LAN nsvmw
p g v buil Demolition permi[is required prior to issuencr..of building �}1,��" ^ IIYa pl�'At (: Ip 1
permit for rte building. ' til 1{ I`'I{�Ifrp' t +ls dfi �QlriAn
�1 jr 1E NIfiO DLAN Sty".
-
Commel'clalBldgs: Provide a completed Hazardous Materials Disclosure 1i1191fl'1 '1 111 Iu T',tYlpl�y � Ir 11y11�•F�IlINl1 ,11'
form if an H zardous Materials are being used as art of this ro'ect. It ( 117 V^ � oT1 PuV,ic� oRRs 1,.
y g P P / � I arldIIK11G , 1 na
_Copy ofP�anning Approval Letter or Meeting with Planning prior to I � �Ilf' plli� II i7P� 11<;� r l� �� y�iljO�`I1�5�P�PT 1
1 1 . 1 'R!ni Fr 't
SubinlltAl Of$pddln Permit application.
� ! 1 (III I 1 V I Nl va\' EWF)R DI&TNCT:
g PP
1 1 M 11!('Ar;rJ t, �I EN.vInoNMENmn��uneDTn �.
1
- BldgApp_70ll.doc revised 03116111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
• ADDRESS: 20900 homestead rd DATE: 11/0412011 REVIEWED BY: bobs.
APN: BP#: VALUATION: $20,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM
USE: PERMIT TYPE:
WORKiremodel kitchen and install W/D hook-up, add new A/C unit.
SCOPE
Mech.Plan Check 0.0 hrs $0.00 4'/vnrb, )'Iran Clrcok Elan.P/nn C'hm:/'
Mech.Permit Fee: IMPERMIT Mun:h_l'e,nrit Fie: Elac. Pe,nrir Hare:
• Other Mech. Insp. 0.0 hrs 1 $44.00 t)ther Phar")lnup. Ej Other t_(c.:. hrsp. ED
Piech.In,ep.Peer P/mn/r. havp.Fae: Eler.Imp, Fee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . These fees are based on the prelhadna Information available and are only an estimate. Contact the Dept foraddn7 into.
FEE ITEMS flee Resohdion 11-05311 . 7/1/11) FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 50 s.f. Remodel,Kitchen(<=300 so
Suppl. PC Fee: Q Reg. () OT 0.0 hrs $0.00 $588.00 IREMRESKIT
PME Plan Check: $0.00 F-T-1 # Mechanical
Permit Fee: $0.00 $65.00 IBREMAIR I A/C Units(<=10K cfm)
Suppl. lnsp. Fee:Q Reg. Q OT 0,0 hrs $0.00 = # Mechanical
PME Unit Fee: $0.00 $130.00 IBAPPLOT I Other Appliance/Equip
PME Permit Fee: $44.00
Construction 7Y1.r
Administrative Fee: IADMIN $41.00 Q
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning Fee: $0.00 Select Non-Residential 0
Travel Documentation Fee: ITRA VDOC $44.00 Building or Structure
Strong Motion Fee: IBSEISMICR $2,00 Select an Administrative Item
• Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $132.00 $783.001' TOTAL FEE: $915.00
Revised: 10/01/2011
• CITY OF CU13ERTINO
8 ITEMS OF 32 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32609065 . 00
DATE ISSUED. . . . . . . : 11/04/7011
RECEIPT # . . . . . . . . . : BS000015241
REFERENCE ID # . . . : 11110022
SITE ADDRESS . . . . . : 20900 HOMESTEAD RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINTO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PROMFIT;:17 JS
ADDRESS . . . . . . . . . . : 1900 S NORFOLK ST STE 150
CITY/STATE/ZIP . . . : SAN MATI70, CA 94403
RECEIVED FROM . . . . : RICH' D REGA
CONTRACTOR . . . . . . . : BEN R::CA LIC # 32275
COMPANY . . . . . . . . . . : MONTER!3Y CONSTRUCTION COMPANY
ADDRESS . . . . . . . . . . : 88 MOfd'!'Ei2EY-SALINAS HWY STE A
CITY/STATE/ZIP . . . : SALINTAS, CA 93908
TELEPHONE . . . . . . . . : (831) 601-2659
• FEE ID UNIT . QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 .00 x11 . 00 0. 00 41 .00 0. 00
1BAPPLOTHE NO OF APPLIAN 2 . 00 1.30. 00 0. 00 130 . 00 0 .00
1BCBSC VALUATION 20, 000.00 .1. . 00 0 . 00 1. 00 0.00
1BREMAIRHA NO.UNITS 1.00 X5 . 00 0 . 00 65 . 00 0. 00
1BSEISMICR VALUATION 20, 000.00 2 . 00 0.00 2 .00 0. 00
1MPERMITFE FLAT RATE 1. 00 14 . 00 0.00 44 .00 0. 00
1REMRESKIT SQ FEET 50 . 00 588 . 00 0. 00 588 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 .1 . 00 0. 00 44 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 9: 5 . 00 0. 00 915 . 00 0. 00
• CITY OF CUPERTINO
ITEM 4 OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32609065. 00
DATE ISSUED. . . . . . . : 11/07/2011
RECEIPT #. . . . . . . . . : BS000015248
REFERENCE ID # . . . : 11110022
SITE ADDRESS . . . . . : 20900 HOMESTEAD RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PROMETHEUS
ADDRESS . . . . . . . . . . : 1900 S NORFOLK ST STE 150
CITY/STATE/ZIP . . . : SAN MATEO, CA 94403
RECEIVED FROM . . . . : MICHAEL FURTADO
CONTRACTOR . . . . . . . : BEN REGA LIC # 32275
COMPANY MONTEREY CONSTRUCTION COMPANY
ADDRESS . . . . . . . . . . : 88 MONTEREY-SALINAS HWY STE A
CITY/STATE/ZIP . . . : SALINAS, CA 93908
TELEPHONE . . . . . . . . : (.831) 601-2659
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 2 .00 82 . 00 41. 00 41. 00 0 . 00
1BAPPLOTHE NO OF APPLIAN 2 . 00 130. 00 130. 00 0. 00 0 . 00
1BCBSC VALUATION 20, 000.00 1. 00 1. 00 0 .00 0. 00
1BREMAIRHA NO.UNITS 1.00 65. 00 65 . 00 0 .00 0. 00
1BSEISMICR VALUATION 20, 000. 00 2.00 2. 00 0.00 0 . 00
1MPERMITFE FLAT RATE 1. 00 44 .00 44 . 00 0. 00 0.00
1REMRESKIT SQ FEET 50 .00 588. 00 588. 00 0 .00 0. 00
1TRAVDOC FLAT RATE 1. 00 44 . 00 44 . 00 0 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 956. 00 915 .00 41 .00 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT
------------------
CREDIT CARD 164 .00 VISA
---------------
TOTAL RECEIPT 164 . 00
•