12010173 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22116 LINDA VISTA PL CONTRACTOR:S& B PERMIT NO: 12010173
CONSTRUCTION
OWNER'S NAME: DAVID GOORVITCH 1294 CALDWELL CT DATE ISSUED:01/30/2012
OWNER'S PHONE: 4082579041
SUNNYVALE, CA 94087 PHONE NO:(408)529-1818
[l' LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG 1_ ELECT PLUMB
License Class � Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor --� Cf:/�-�I J?14 ire � - -3�' l Z
JOB DESCRIPTION: REMODEL 60 SQ FT TO M.BATH INCLUDE HEADER FOR
I hereby affirm that I am licensed under the provisions of Chapter 9 POCKET DOOR,ROLL IN SHOWER FOR ACCESSIBILTY
(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. Sq.Ft Floor Area: Valuation:$5000
1 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 APN Number:35608010.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued by: �/ ,x, /J Date:
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.
RE-ROOFS:
Signatu
Date _ Z 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.
❑ OWNER-BUILDER DECLARATION Date:
Signature of Applicant:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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)
HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sections 25505 533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this —' — Date:
Owner or authorized agent:,
permit is issued.
I certify that in the performance of the work for which this permit is issued,1 shall
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,1
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: -2-2- //6- 1V0A Yom,A PERMIT# l Zo l D 7
OWNER'S NAME: v; C) z PHONE# ted-56xl- 717
GENERAL CONTRACTOR c ✓'1j �; -�LYv BUSINESS LICENSE# Zr
ADDRESS: /Z 9y CITY/ZIPCODE: 1-' 'e
*Our municipal code requires all businesses working in 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.
�_ -- /2
I am not using any subcontractors:
L--, !4ignatdre Date
Please check applicable subcontractors and complete the following information:
j/ 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
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # : 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN 35608010 . 00
DATE ISSUED. . . . . . . : 01/30/2012
RECEIPT # . . . . . . . . . BS000015868
REFERENCE ID # 12010173
SITE ADDRESS 22116 LINDA VISTA PL
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER DAVID GOORVITCH
ADDRESS . 22116 LINDA VISTA PL
CITY/STATE/ZIP CUPERTINO CA, 95014-4022
RECEIVED FROM S & B CONSTRUCTION
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 5, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1REMRESBAT SQ FEET 60 . 00 588 . 00 0 . 00 588 . 00 0 . 00
---------- ---------- ---------- --
TOTAL PERMIT 589 . 50 0 . 00 589 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 589 . 50 visa
---------------
TOTAL RECEIPT 589 . 50
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 22116 Linda Vista PI DATE: 01/30/2012 REVIEWED BY: RDW
ApN. BP#: VALUATION: $5,000
PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Remodel, Bath (300 s.f. max)
PRIMARY PENTAMATION 1 R3SFDREM
USE: Residential PERMIT TYPE:
WORK Remodel M/bath including header for pocket door. Roll in shower for accessiblit .
SCOPE
P
FLR AREA
AT 60
E3-L-
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These Lees are based on the preliminary information available and are only an estimate. Contact the De t or addn't info,
FEE ITEMS rrtioll I1-OS:;LAA ";'L 111 FEE QTY/FEE MISC ITEMS
Permit Fee: $588.00
Work Without Permit? } Yes (j) No $0.00
Sta•arX<,, t�lt�lic ct 1='`e: IBSEISLIICR $0.50 Select an Administrative Item
Bldg SO,,Coi7�missiori Fee: IBCBSC $1.00
SUBTOTALS: $589.50 $0.00 TOTAL FEE: $589.5
Revise . /2012
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building(cDcupertino.org `
CUPERTINO l l�
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT it
LPR:OIECT ADDRESS APN#
3 0- U s`�c,_ l a C_�. P
NAME PHONE E-MAIL
V �' RV' L as--7 'dr i�c c . /U
STREET ADDRESS �,I CITY,STATE,ZIP FAX
2 Y I S+ci G e>r A 9SOl
CONTACT NAME PHONE E-MAIL
_T
STREET ADDRESS CITY,f
E, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER / LICENSE TYPE BUS.LIC#
COMPANY NAME
n E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK nn 0. r m
YYL-d max^-Q�- L°-` 0✓
zxL /O`er +C)o X&<s
EXISTING USE PROPOI�USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLO''Off??R`` DEMO �V/ TOTAL
�A AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA / REMODEL AREA REMODEL AREA
PORCH AREA ('DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: ❑DETAACH
#DWELLING U7 IS A SECOND UNIT ❑YDS SECOND STORY ❑YF,S
BEING ADDED? $�L o ADDITION? �rila-�O
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN Q�Np5 RECEIXF�D BY: TOTALA T�jAW:
PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? - rvv
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prrperty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state law:relating�tobuild�ingconstru ze representatives of Cupertino to enter the above-identified property for inspection purposes.
.
Signature of Applicant/A Date: / -
SUPPLE TI REQUIRED PLAN Cf7ECK TYLE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for ��-.�-Co�R ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ MRESS ❑ PLANrUNG PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLICWORKS
form if any Hazardous Materials are being used as part of this project. ❑ ❑ DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp 201 Ldoc revised 06/21/11