11110104CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11669 OLIVE SPRING Cf
CONTRACTOR: S & B CONSTRUCTION
PERMIT NO: 111 10104
OWNER'S NAME: ADAMS ROBERT A AND PATRICIA R
1294 CALDWELL CT
DATE ISSUED: 11/182011
ON 'S PHONE: 4082574137
SUNNYVALE, CA 94087
PHONE NO: (408) 529-1818
LICENSED CONTRACTOR'S DECLARATION
r r r
License Class Lie. H�J1 /�
gU1LDING PERMIT INFO: BLDG ELECT PLUMB
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MECH RESIDENTIAL COMMERCIAL
Contractor ! G
K �m
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: SINGLE FAMILY DWELLING BATHROOM
(commencing with Section 7000) of Division 3 of the Business & Professions
REMODEL(40SQFT);NON-STRUCTURAL
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: $6000
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
permit is issued.
APN Number: 36654095.00
Occupancy Type:
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
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 understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Issueclvyy. D
QQ
Signature Date
r OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material berg installed. If a roof is
thereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, 1 agree to remove all new materials for
the following two reasons:
inspection.
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,
Signature of Applicant: 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
I hereby affirm under penalty of perjury one of the following three
declarations:
HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self -insure for Worker's
1 have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. I 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(a) should 1 store or handle hazardous material.
Section 3700 of the Labor Code, for the performance ofthe work for which this
Additionally, should 1 use equipment or devices which emit hazardous air
permit is issued.
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
I certify that in the performance of the work for which this permit is issued, I shall
Health & Safety Code, Sections 25505, 25533, and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Califamia. If, after making this certificate of exemption, I
Owner or ri d e ant: /�/d
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.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
I certify that 1 have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. 1 agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
cnd expenses which may accme against said City in consequence of the
( g of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
w, a I non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
•
•
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36654095.00
DATE ISSUED.......: 11/18/2011
RECEIPT #.........: ES000015352
REFERENCE ID # ...: 11110104
SITE ADDRESS .....: 11669 OLIVE SPRING CT
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............: ADAMS ROBERT A AND PATRICIA R
ADDRESS ..........: 11669 OLIVE SRPING CT
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5141
RECEIVED FROM ....: PATRICIA R ADAMS
CONTRACTOR .......: SABRIJA KUCEVIC LIC # 29043
COMPANY ..........: S & B CONSTRUCTION
ADDRESS ..........: 1294 CALDWELL CT
CITY/STATE/ZIP ...: SUNNYVALE, CA 94087
TELEPHONE ........: (408) 529-1818
FEE ID
----------
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
1BCBSC
-------------
VALUATION
----------
6,000.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1BSEISMICR
VALUATION
6,000.00
0.60
0.00
0.60
0.00
1REMRESBAT
SQ FEET
40.00
588.00
0.00
588.00
0.00
TOTAL PERMIT
----------
589.60
----------
0.00
----------
589.60
----------
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
589.60
---------------
589.60
REFERENCE NUMBER
--------------------
#6848
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
10C1 (408) 777-3228 • FAX (408) 77�7-3333 • buildinG(cbcuoertino.oro
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OWNER NAME ffb3 p.,_M5
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STREET ADDRESS
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FAX
CONTACT NAME C,�v
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STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRA=R ❑CONTRACTORAGENT ❑ ARcHmHrT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME (( ,�� LICENSE NUMBER9j 9 n
95
LICENSE TYPE
BUS. LIC #
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COMPANY NAME iL nD't
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E-MAIL
FAX
STREET ADDRESS12 y C � n
CITY. STATE, ZIP 49n`�T
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PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC#
COMEANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ESCRIP17ON OF WORE
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EXISTING USE
PROPOSED USE
CONS R. T PE
# STORIES
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USE
TYPE
OCC.
SQFT.
VALUATION (S)
EXISTo
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
%�
/
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BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCHAMA DECKAREA TOTALDECK/PORCHAREA (iAAAGE AREA: DETACH
ATTACH
#DWELLING UNITS:
ISA SECOND UNIT YEs
SECONDSTORY ❑YES
BEING ADDEDT []NO
ADDITIOM. []NO
PRE -APPLICATION CITES IF YES, PROVIDE COPY OF
I LSTRRBLDGAN ❑YES
RECEIVED BY:
TOT VAA//jj..��,i�11ATIOlN,:
PLANNI.'GAPIN
PL# 12NO PLANNING APPROVAL LETTER
EICHLERHOME? CINO
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By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prppetty owner's behalf. I have read this
application and the information I have provided is correct I have mad the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws misting to building construc ' msentatives of Cupertino to enter the above-identifiedproperty for inspection purposes.
Signature ofApplicanVAgent: Date:
SUPPLEMENTAL
PLAN CHECK TYPE
ROTTING SLIT
PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for�TT>E-CoatrJZHB7G
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNRNGPIANREVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC'WORKS
form if any Hazardous Materials are being used as part of this project
....
❑ LARGE
❑ I+HIE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
El MAJOR
El 9AMTARY SEWER DISTRICT
bmittal of Building Permit application.
❑ ENVIRONMENTALHEALTH
B1dgApp_2011.doc revised 06/21/11
11
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����� CITY OF CUPERTINO
II FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not Include fees due to other Departments (le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the arelininary information available and are only an esthnate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution II -053 Eff 711111)
ADDRESS: 11669 olive spring et. DATE: 11/18/2011
APN: BP#:
REVIEWED BY: bob s.
"VALUATION: 1$6,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
FIec' Permit Fee:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK sfd bathroom remodel non structural
SCOPE
NOTE: This estimate does not Include fees due to other Departments (le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the arelininary information available and are only an esthnate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution II -053 Eff 711111)
3feell. Plan Cheek
I'&un L_ Pian Check
Elec. Plau Check
Mock k Pcrmrs Fue: �
Plundi. Pamtit Pce:
FIec' Permit Fee:
011ier AIr,:Ir. Inap,
Odmr Plunih hasp.
c)!hru I-/ec. h1v'.
Hod,, Imp. Fee:
Pluwb. Ar.tp. l-'er:
Diet. Inp. Pee:
NOTE: This estimate does not Include fees due to other Departments (le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the arelininary information available and are only an esthnate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution II -053 Eff 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
40 1 s.f.
$588.00
Remodel, Bath (<=300 so
IREMRESBAT
Suppl.PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
furs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Cof)strnc(iun Tar
Administrative /,'ee
O
0
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select Non -Residential
Building or Structure
0
%r�rvul i)n<annc�nt�rriarr F us:
Strong Motion Fee: IBSEISMICR
$0,60
Select an Administrative Item
BldgStds Commission Fee: IBCBSC
$1.00
i. SUBTOTALS:$1.60
$588.00
TOTAL FEE:
$589.60
Revised: 10/01/2011
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IOUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: 11Q0 a 646- S �A) CC -1
PERMIT #
OWNER'S NAME: -a- /, S
PHONE #
GENERAL CONTRACTOR: t9 MpL t ov;c
BUSINESS LICENSE #
ADDRESS: I'Z61ti CAt v✓o-tc
CITY/ZIPCODE:
*Our municipal code requires all businesses working (n the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.// �T / /I— //
I am not using any subcontractors: !
�gnature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date