12020066CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19971 LA MAR DR CONTRACTOR PERMIT NO: t2020066
OWNER'S NAME: DAVE & LINDA WYCKOFF � � 1�'v; rJ. ATE ISSUED: 02!14/2012
PHONE NO:
OWNER'S PHONE: 4082524707
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #'
Contractor,kdr✓ -5C,'^ 6h5 Date 2
I hereby affirm that I art► licensed under the provisions of Chapter 9
(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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of die work for which this
Permit is issued.
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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnity and keep harmless the City of Cupertino against liabilities, judgments.
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Sectice
Q. 18.
BUILDING PERMIT INFO: BLDG' ELECT" PLUMB
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: REPLACE SHOWER STALL ONLY, NO ELECTRICAL & NO
LIGHTING
Sq. Ft Floor Area: I Valuation: $6680
APN Number: 36910040.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
V-/
G(—/ Issued by: - Date:
Signature /' Date
-r
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the C'ontractor's License Law for one of
the following two reasons:
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)
L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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.
I certify that in the performance of die work for which this permit is issued, I shall
not ernploy 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
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.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above intormation 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all lion -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed withoutt first obtaining all inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
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
Health & Safety Code, Sections 25505, 25533, and 25534.
I
Owner authorized agent: 2 ,� I' L/—
Date: -(
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date I Licensed Professional
CITY OF CUPERTINO
IPF F F 4ZTIM A TnR — R1 T11,DING DIVISION
LaADDRESS: 19971 la mar ave.
DATE: 02/14/2012
REVIEWED BY: larry s
i APN:
BP#:
VALUATION: 1$6,680
1 PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Suppl. PC Fee: 0 Reg. 0 OT
PENTAMATION 1 R3SFDREM
I PERMIT TYPE:
WORK
replace shower stall only, no electrical, lighting.
SCOPE
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Flanningvublic worKs, r1re, 3anuaty newer vistria, acnool
C""toet tho Dow for addn 91 info.
-----------
FEE ITEMS 1 (-t'2.,i3 E,6f 7 1 1!)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: 0 Reg. 0 OT
El
hrs
$0.00
PNIE Plan Check;
$0.00
Permit Fee: Hourly Only? (D Yes 0 No
$0.00
Suppl. Insp. Fee.G Reg. 0 OT
UE
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
0
Work Without Permit? 0 Yes G No
$0.00
"Wv,-Inct"d 1-1,11if"UM!
$0.00
hours
$260.001
Inspections
ISTINSP Inspection, Hourly
E)
0
StL!,3gl, '1006 ("n-: FeIBSEISMICR
. .. ... .............
$0.67
M1 hrs
$41.00
Admin./Clerical Fee
]ADMIN
B1(4v, stds Co�-rlfflissi('J) Fee,: IBCBSC
$1.00
SUBTOTALS:
$1.67
$301.00
TOTAL FEE:
1
$302.671
Revised: 1/19/2012
CUPERTINO
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: 0171
G; 410- PERMIT # 21 -Lo
OWNER'S NAME: r, Iv- `i`
e PHONE # 'L r "Z- 7
GENERAL CONTRACTOR:
-BUSINESS LICENSE #
ADDRESS: fe,�( ,,r
„ `l ITY/ZIPCODE:
*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.
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
2 - i�- /,Z-
Date
2Date
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
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(c-Dcupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI „ ❑ REVISION / DEFERRED ORIGINAL $ERMIT #
PROJECT ADDRESSf (I l / n� ���
APN $ n _ Ltv
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OWNER NAME ,
PHONE
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FAX
OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME 1
LICENSE NUMBER._ It-7,LICENSE
TYPE R
BUS. LIC #
COMPANY NAME
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E-MAIL
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FAX ?"
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STREET ADDRESS f3,1
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PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK �l� I ��
4-,u e-7 �✓ G . Gam.
EXISTING USE
PROPOSED USE CONSM
TYPE#
STORIES
r-
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTAREA G
AREA FLOOR
DEMO�� 20
TOTAL
NET AREA
/
CG !)
BATHROOM ^
REMODEL AREA ®�
KITCHEN
REMODEL AREA
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: U DETACH
ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? JaNO
ADDITION? QNO
PRE -APPLICATION Q YES IF YES, PROVIDE COPY OF
IS THE BLDG AN [3 YES
RECEIVED BY:
TO AL, CATION:
PLANNING APPL # A NO PLANNING APPROVAL LETTER
EICHLER HOME? g NO
6 r,
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 laws relating to buil ng cons ction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
2- J
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
LJ' VER -THE -COUNTER
Bi1II DING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING 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.
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANrrARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp_2011.doc revised 06/21/11