12030048 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 20900 HOMESTEAD RD CONTRACTOR:MONTEREY PERMIT NO: 12030018
CONSTRUCTION COMPANY
OWNER'S NAPIE: VS H LP 88 MONTEREY-SALINAS HNT STE A DATE ISSUED:03/098012
OWNER'S PHONE: 6509313400 SALINAS.CA 93908 PHONE NO:(831)601-2659
❑ LICENSED CONTRACTOR'S DECLARATION r r r
9 BUILDING PERMIT INFO: BLDG ELECT PLUMB
License C(azs_ Lie.q r r r
MECH RESIDENTIAL COMMERCIAL
Contract ate
herehy infirm that I am licensed under the provisions of Chapter9 JOB DESCRIPTION:BLDG 75 UNIT I-CONVERT 45SQFI'CLOSET INTO
commencing with Section 70(N1)of Division 3 of(he Business&Professions SECOND
Code and that my license is in full force and effect. BATHROOh1(SEE PERh11T p1105012 POR PLANS)
herein,
atlirin under penally of perjury one of Ibe 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
Perfo finance of the work for which(his permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for We performance of the work for which this Sq,Ft Floor Area: Voluation:$5000
permit is issued.
APPLICANTCERTI FICATION APN Number:3260907200 Occupancy Type:
I certify that I have read this application and stale that the above information is
correct.I agree to comply with all city and county ordinances and slate paws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned proper,to inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which muyaccrue against said City in consequence ofthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this pemik. Additionally,the applicant understands mid will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulatiais per the Cupertino Municipal Code,Section
3
Issued by:
Signature JEA/� f�TGy Date:
❑ OWNER-RUILDER DECLARATION
RE-ROOFS:
hereby affirm that 1 am exempt from the Contractor's License Law for,one of All mors shall be iayiected prior to any roofing material beiig installed If a roof is
the following two reasons: installed without till obtaining an inspection,I agree to remove all new,materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do die work,mid the structure is no(intended or of2red for sale(Sec.7044,
Business&Professions Code) Signmure of Applicant: Date:
I,as owner of the property,ani exclusively contracting with licensed contractors to
construct lite project(Scc.7(I44,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 Certifieme of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Aide,for the I have read the hazardous materials requirements under Chapter 6.95 of the
Perfonnance of the work for which this pemhi(is issued. California Health&Safety Code,Sections 25505.25533.and 25534. 1 will maintain
I have and will maintain Wor4:er's Compensation insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for(he performance of the work for which this Safety Code,Section 2.5.532(a)should 1 store or handle hazardous mo(erial.
Additionally,should I use equipment or devices which tacit limrdous air
Permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
I cenify that in the performance of the work for which this permit is issued I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505.25533,and 25534.
Compensation paws ofCalifomia. lf,after making this certificate of exemption,l
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or tut o i di ge"t 7 /
IJnhwith comply with such provisions or this permit shall be deemed revoked. Date: 3
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
(certify thin I have read this applicmion and state that the above information is I hereby affirm thm there is a construction pending agency for the performance of work's
correct.I agree to comply with all city and count ordinances and state laws relating for which this permit is issued(Sec.3097.Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indenhniN and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
coasts,and expenses which may accrue against said City in consequence of the
ipi(ing of(his Permit.Additionally,die applicant understands and will comply ARCHrmn"S DECLARATION
with ail non-poim source regulations pet the Cupertino Municipal Code,Sectio
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
2.14 ADDRESS: 20900 Homestead Rd DATE: REVIEWED BY:
APN: BP#: "VALUATION:
{PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY 'or Duplex PENTAMATION 1 R3SFDREM
USE: PERMIT TYPE:
WORK Convert45 sq It closet into second bathroom. See permit 11050122 for plans.
SCOPE
.t mit. 111,0+Chcrk Plunub. Plan Check Elec.Plan Cbcck
Ale:h Per oit FeePlanth.Patron Fee: Dec. Permit Fee'
Ut1nv''Ifivit Inst. (')the).Plttnuh 1,--E]--L- Other Elea In
Imp Fee Plunrb. inep.Rr•: Fier.Imp.Fee:
NOTE: This estinmte doer not include fees due to other Departments(ie. Planning,Public 11 arks. Fire,Sanitary Sewer District.School
District,etc). These fees are based on the prelininan'in ornetion avrdlnble and are ants,an eainurte. Contact the De 1 or addn'I info,
FEE ITEMS (Fee Resolution 11-053 EH 711111) FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 45 s.f. Remodel, Bath(<=300 so
Suppl. PC Fee: Q Reg. O OT 0.0 Tilts $0.00 $588.00 /REAIRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
SuppI. Insp. FeeQ Reg. Q OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Cauytruction Tax:
Atlntinisrrutive Fee. Q
Work Without Permit? 0 Yes (j) No $0.00 (D
Advanced Plannine Fee: $0.00 Select a Non-Residential E)
Tray!Ducntnenlarion Fees:
Building or Structure 0
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $588.00 TOTAL FEE: $589.50
Revised: 1/19/2012
03/08/2012 10 : 27 (FAX) I cc T-&02/002
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT" BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
CUPERTIN0 (408)777-3228 ' FAX(408)777-3333 ' bulld4nq(c7cuperllno.ofq
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❑NEW CONSTIiUC 'ION ❑ ADDrf10N �IALTERA"r10N/TI ❑ RFVISION/DEFERRED (ORIGINAL PE%MIT9
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By my signature below,I certify to coati of the following: '1 dm Lhe limocny owner dr.authonrrd agent td act on the property owner's hdtnl f. 1 hR've recd(his.
ordinances and theinformation
(-Ei I have d vi))lad is correct.4 have read the Descnplion or Work and verify ii is occurale. 1 agree to wmply wish aII opplicablc local
ordinances and dale laws relating( 7gconsuucii6n.-I authorize rcprrzenlalivev efCupmino Ld enter the above ali1jlied�('ODer rinsdeclion purposes.
Signature of Applicant/Agent:_'
SUPPLEMENTAL-INFORMATION IZLQ UIRL4 •.. "- i E,1!jppII Inxu�,ll,1yy'IfI:n lGG ratM1M1 anolE,,rh y, rH7 Is;.p
, �., , , 7:.s4�l�tr Ary�CI1FCK{TINEEAP%I51,LIE Yr-�Ir.!''bll�liiillOUTINGSL11� ;'.
New SFDor Mulufnnllydwclliitgs: Apply'fordemohuoit pennit for ,. ri'r11'l etJlJ;hIT;V[111LtaII1.JfLk{'I'lrY'� I,'P'o'Pvjv,:)' UrJ, Mi.w} 1
I 1 QVl Ir I t f UN'f�H J1�41, j I❑. BUIL DINC PLAN REVIESV
existing buildings) Deliialuioli perinn,l,5 regmred prior to Issuatic oCbut _jitg.. ,�lA III `IY,17 aGl�y II IP' n I d) I c t '� r
permit for new budding - „ )AF11I�L �j,6"` �(`d'� Iy fveKhl 419'W.�JI
"Mill,V
a. 'SirP "G'.�Jr1. I a O'rpkN+M1'1NG PLA N-I YI.
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ml�ercial Bldgs Provide a completed Iiazirdous Materials Disclosure ® £ 1 T r1.11 t 11" ,Il;fl y J S �C
5 A�'UARU� I,- )•.0 I OL"runuic WOIiIrs1; ,`a
Corm If an Hazardous Matennls arc bang used as partof.I prolcyt
'yC1I( R�tIuJpa Iht r t TI\e Derr P�P�3 I,J
_Copy ofFlannIng Approval Letter or MLLtlnb with Planning prior lo' �WFill'ili�le)4'l - Ij J!r�,'.i�t'�✓1 r. a•I,rSI'4e JAVIt I
Sublrlittal of Budding Penni(application `L`Y�°yr %bl+ dt J��(jf( � Efi�IrSP�xTnRYISESYEHEDISTftILT:
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