12030013 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10375 BYRNC A VE CONTRACTOR: PERMIT NO: 12030013
OWNER'SNAME: AUGUSTIN CHANG 41 • tLsi(LU(IT-j l� DATE ISSUED:03/052012
OWNER'S PHONE: 4085615565 PHONE NO:
❑
LICENSED CONTRACTOR'S D
E
CLARATION BUILDING PERMIT INFO: BLDG r ELECT[ PLUMB F-
License Class L Lic.3 N o v T
MECH r RESIDENTIAL r COMMERCIAL r
Covmetor/p t�P� I7 Ann Date 3 � L
hereby affirm that 1 out licensed wider the provisions of Chapter 9 •10B DESCRIPTION:BATHROOM RENtODEL(12.1SQFT)
(commencing with Section 71100)of Division 3 of the Business&Professions '•SEE NOTES-
(commencing
Cade and that m)•license is in full force mud effect.
1 hereby affirm under penalty M.perjury one of the following boo declarations:
(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 Sq.Ft floor Area: Valuation:$15000
Section 3700 of the Labor Code,for the perfomamee of die work for which this
permit is issued.
APN Number:35712030.00 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 Imus 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
indenmify and keep hanmess(lie 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 understaids and will comply
with all non-point sourccr gulations pe die Cupertino Municipal Code,Sectirn
9.13. _ Issued by: ��A� �/ATG�/ Date: .3 f•/a'
Signature Date
❑
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hertbp affirm that 1 am exempt from the Contractor's License Law for mese of installed witlmu first obtaining tat 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 As their sole compensatiivf,
will do the wort:.and the structure is tot 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 R Professions Code). ALL ROOF COVERINGS TO BE CLASS"A\"OR BETTER
I hereby affirm under penalty of perjury ane 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 die Labor Code,for the California Health&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
performance of the wort: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(x)should 1 store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which email hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
pemnit is issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify max in the performance of die work for which dais 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 California. If,after making this certificate of exemption,I Owner or am[har•ized agent.
become subject to the Worker's Compensation provisions of the Labor Code,I must 6=4 Dater Z
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 I have read this application mid state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I acne to comply with all city and comity 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.('Ale)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall he used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
4 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35712030 . 00
DATE ISSUED. . . . . . . : 03/05/2012
RECEIPT #. . . . . . . . . : BS000016181
REFERENCE ID # . . . : 12030013
SITE ADDRESS . . . . . : 10375 BYRNE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : AUGUSTIN CHANG
ADDRESS . . . . . . . . . . : 10375 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2811
RECEIVED FROM . . . . : EVERGREEN HOUSE
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- - --------- ---------- ---------- ----------
-ADMIN HOURS 1 .00 41 . 00 0 . 00 41 .00 0. 00
1BCBSC VALUATION 15, 000 .00 1 . 00 0 .00 1 .00 0 . 00
1BSEISMICR VALUATION 15, 000 .00 1 .50 0 .00 1 .50 0 . 00
1REMRESBAT SQ FEET 122 .00 588 .00 0 .00 588 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 631.50 0 .00 631.50 0. 00
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADRESS: 10375 Byrne Ave DATE: 03/0512012 REVIEWED BY:
APDN: BP#: "VALUATION: $15,000
•PERMITTYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM
USE: PERMIT TYPE:
WORKBathroom Remodel 122 sq h
SCOPE
.t A It P.m Chick Plumb. Plan O jmk Flee.Plan Check
Mecn. Penta Fee. Plumb.powul Fee: Elec.Permit Fee'
other,ifech.lrq). Oulu'Pluath leap. Olbt, tiles. h Sp. Li
11a.h./nil, pore- Plunb.lisp.Pie: Flee.Int).Fee:
NOTE: This estinuve does not include fees due to other Departneetus(i.e. Planning,Public Works,Fire,Sanitary Seuvr District.School
District,etc.). Thesefees are based on the trelininaninformation available and are only an eslintate. Contact the Dept for addrt7 info.
FEE ITEMS (Fee Resolution 11-053 ER 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = s.f. Remodel, Bath(<=300 SO
Suppl. PC Fee: (D Reg. Q OT 0.0 hrs $0.00 $588.00 IREMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee<D Reg. Q OT 1 0.0 1 [its $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
COnsn•uclion Tis:
Athainishvtive Fee: O
Work Without Permit? 0 Yes Q No $0.00 E)
Advanced Plannine Fee: $0.00 Select a Non-Residential G)
Tramll Dacurneniatiort Fens:
Building or Structure 0
Strong Motion Fee: IBSEISd1ICR $1.50 0.5 ]its Admin./Clerical Fee
Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 laDA11N
SUBTOTALS: $2.50 $629.00 TOTAL FEE: $631.50
Revised: 1/19/2012
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By my signature below,I certify to each of[he;ollowin : I=the property owner or authorized umt to act an the prppeny owner's behalf.•1 have tend thisv
application and the information I have o c, I haye the Description of Work and verity it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin I o representatives of Cupertino to emer the abovc4denti5ed property for inspection purposes.
Signature of ApplicanJAgrnn pate:
SUPPLEMENTAL NFORMATION REQUIRED PLAY cm:CK TYPE ROTMG SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for over-rtlE-cotmTex ❑ etm.ncrc Pt.A.v REVIEW
existing building(s). Demolition permit is requited prior to issuance of building
permit for new building. ❑ eaRESS ❑ Pt.,svvcvc PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PVRUC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE Cl Fina ut•T
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ .woR ❑ SANITARY SEWER nis-rRlcr
submittal of Building Permit application.
❑ E.YVnto,Y. YtA REALTH
BldgApp_1011.doc revised 06111111
- — — — - -�� A&PA&s 4pp_20ll.doc revised 0621111
I
2�3��►3
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
(408)777-3228 • FAX(408)777-3333• buildinc(@,cuoeTSno.orG
GUPERTINO -
El NEW CONSTRUCTION ❑ ADDITION ALTERATION/IT ❑ REVI5I0N/DEFERRED ORIGLNIAL P tER,MIT p
PROJECT ADDRESS / V -7 Av'& I APN4 �/ �i
OWNER NAME AGL ('t'T;t" O`
EET khe� PHONE // _a per/ ' �Ji6y E-MAR
STRADDRESS /O -7 /j /1 V CITY. STATEZZIPJo } C/ FAX '
Cw ev f'Ito
CONTACT NAME /( I(eo 1--[ L 12 PHONE �o S-G/ - / E-MAIL
STREET ADDRESS /Y 73 /"1 e r' I i a N A-01- CITY.STATE ZIP ^/ D FAX
Q CS �,/ psi )ofd
❑ OWNER 1311 �!
OWNER-BUILDER OWNERAGENT 'CONrRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAMElIe�t i (a 11 LICENSE NUMBO ER 65Q LICEN TYPE BUS.UCp
COMPANY NAME p I E-MAIL FAX
y0./ S C.o l 5 frN.eil r D h
STREET ADDRESS l 0 7 3 /t'ei,' lI'QI,I A'`� CITY.STATE ZIP 5a, 7o s PHONE
CTB
AATECT/ENGINEER NAME / O /� LICENSE NUMBER BUS.LIC p
COMPANY NAT¢ E-MAIL FAX
STREETADDRESS / / CITY.STATE,ZIP I PHONE
DESCRPRON OF WORK /I. D /Q
Ex67II+G USE PROPOSE co. SS TIPE 0STORIES USE I TYPE I OCC. SQFr. VALUATION(S)
AREA /-3 NEW FLOOR - 3 DEMO �•JL NE7rTarALA 03 �D /� O[x/
= AREA AREA NET ARFA
BATHROOM KITCHEN OTHER
REMODELAREA /�J{ REMODEL AREA REMODEL AREA
PORCH AREA 'DECK AREA TOTAL DECKFORCH AREA• GARAGE AREA: DETACH
ATTACH
p DWELLING UNITS: IS A SECOND UNIT ❑YEs SECOND STORY ❑YES
BEING ADDED! []NO ADDITION'. []NO
PRE-APPLICATION ❑YES IF YES.PROVIDE COPY OF / IS THE BLDG AN L]YES RECEIVED BY' TOTAL VALUATION:
PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOTIE7 NO
fA/� / DT D
By my signature below,I certify to each of the following: I am the property owner or authorized anent to act on the prppcny owoer's behalf-I have read this
application and the information I have provided i y> ,c I haye gr
d the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and Sam laws relating to buildin I t o representatives of Cupertino in enter the above-identified property for inspection purposes.
5ignatttre bf.4pphcanVAgenO Date:
3 -
SUPPLEMENTAL INFOILNfATION REQUIItED Pw.NCHECICTYPE I ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit foroven-r[IP-corJN'rER ❑ BIiD,ncrc PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVJEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STA.NDAaD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ GE ❑ ms bar
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ nwoR ❑ SANITARY sEwat DISTRICT
submittal of Building Permit application.
❑ ENVIno Y�IE.YTAL HEALTH.
BldgApp_201 Ldoc revised 06/21/11