09040126 CITY OF CUPERTINO n�� � ;� �N*
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: 196
1119 TBDRF
PERMIT ISSUE DATE
OWNER'S NAME:
A CONTROL NO.
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECTPLUMB 0
MECH
a p Q LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
u,5 with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is CODERS 0l C L S ET AREA TO 1/2 BATH
=H in full force and effect
v�Z License Class
Date Contractor
ARCHITECTS DECLARATION
aI understand my plans shall be used as public records
m<
�yU
L a H Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law far the
In O following reason.(Section 7031.5,Business and Professions Code:Any city or county
,S P which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement ;q-Ft.Floor Area Valuation
?< that he is licensed pursuant to the provisions of the Comractoes License Law(Chapter 9
YH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5000
IRS that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). 36226015 . 00
❑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 sok(Sec.7044.Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License law' B&P C for this reason
❑I am exempt under Sea
Owner Date 4'2''
CER'S OMPENSATTON DECLARATION
1 he der ty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
I certifv that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
(..t►-. I hereby affirm that there is a construction lending agency for the performance of
(]! the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
11, Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL H torten.1 agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city to enter upon the
Gla above-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City o 9
U Z in consequence of the granting of this permit. Date (/
-- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b3:
SOURCE REGULATIONS.
`I 23 Loo` Re-roofs —
SXgnat of t/M.0u.1-rc
r Dam 'I of Roof
HUS MATERIALS DISCLOSURE Type
ill the applicanbuilding occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
nYes C]No If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
AOWI,.mit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the Date
re ircments which must be met rior to issuance of a Certificate of Occupancy. S lgnaturl:of Applicant
t3 All roof coverings to be Class" "or better
Own or a d age
Date •
CITY OF CUPERTINO
ADDITION/REMODEL
CUPERTINO FEE SCHEDULE
APN # Date:
36-7- 2,b -01,V , UO2�
Building Address: /I
r Cl 1
40/1
Mailing Address (if different from building address):
Owner's Name: ,fe- r 0 D� Phone# : #O
_8 3,
T
HOA: Exterior work Yes F-1NoE!]"
(
If yes, provide letter from HOA
Contractor: Phone#:
Fax #:
Contractor License#:
Cupertino Business License#:
Contact: Phone#:
Fax #:
Building Permit Info:
Bldg. ® Elect. ❑ Plumb. [] Mech. ❑ Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
�.oh vers s oll Of G(o sed CL-r-m -�o �z ��►,
What is being remodeled (not including addition)?
Remodel Includes Re-Roof. Yes ❑ No D� If yes list number of squares
Remodel Includes Structural: Yes ❑ No [d
Do you have the pre-application planning approval? Yes ❑ No
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath l Other
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ IUIII B, IV-HT, --B E9-- `2
Valuation: a 000 Please check this box if the project is a
second-story addition ❑
Project Size: Express ❑ Standard ❑ Large ❑ Major❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved: G'
include in plan set& the sheet index.
***For Office Use Only***
F-1Revised 02/05/09
Over-the-Counter
CITY OF CJPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Sq Ft Group ADDITIONS 1R3SFDADD
PLLONGRNGR Long Ran€;e PL
Planning/Residential
1 R3INSP Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1R3REPPLNC Dwellings Repeat Plan B
Check
1 R3HINSP Dwellings Hillside B
inspection
1 R3HPLNCK Dwellings Hillside plan B
check
1 R3HREINSP Dwellings Hillside B
Repeat Inspection
1R3HREPLNC Dwellings Hillside B
Repeat Pl,,m Check
1R3ALTINSP Dwellings Alternate B
Materials Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check
1 PCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
Disposal System
1 PRSEWER Sewers P
1 BP SPRINK Lawn P
Sprinkler Backflow
1BPWSVCS Main Wa:er Service P
1 BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1 BSEISMICRE SeismicR esidential B
1REROOFRES Residential Re-roof Each B
100 SF
CITY OF (:UPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Sq Ft Group DECKS 1R3SFDADD OR
1R3SFDREM
1 DECKWOOD Deck (VG ood)-Each B
(Each)
1DECKRAIL Deck Railing-Each B
(Each)
GARAGES 1R3SFDADD OR
DETACHED 1R3SFDREM
1 GARDTW<=1 K Wood Frame up to B
1,000 SI' (each)
1 GARDTM<=1 K Masonny up to 1,000 SF B
(each)
BCONSTAXR Construction Tax Res
(new de'.ached garage)
PATIO'S OPEN 1R3SFDADD OR
1R3SFDREM
1PATIOWOOD Wood Frame up to 300 B
SF
1 PATIOMETAL Metal Frame up to 300 B
SF
1 PATIOOTHER Other F-ame up to 300 B
SF
PATIO'S CLOSED 1R3SFDADD OR
& SUN ROOMS 1R3SFDREM
1PATIOENCLW Enclosed Wood up to B
300 SF
1 PATIOENCLM Enclosed Metal up to B
300 SF
1 PATIOENCLO Other Enclosed Patio up B
to 300 ISF
1 COVPORCH Porch Covered-Each B
(Each)
REMODELS 1R3SFDREM -
1REMRESKIT Kitchen Remodel up to B (Deduct "$"for ea plan
300 SF check
1REMRESBAT Bath R.-model up to 300 B "
SF
1 REMREOTH Other Remodel up to 300 B "
SF
RESIDENTIAL PROJECT-COVER SHEET
Assessor's Parcel Number: 6d -Z6 'Uls
Name of owner.
Project address. l/9 /�o Il4 he-ad Le!v�, �-�� �iho , C � 9s-0 I�G
Contact person. Ph)ne. 40 8- Y1.3 - g9s-9
6�3 - 33 2 9
Net square footage of lot.
Existing Proposed
Square footage: First floor: %I 0 11(7o Ino
Second floor: ZZ'S-1 s b rw
Garage: 10 q 9 no Cht
TOTAL: 2.09S �09�
Are there at least two 10 foot by 20 foot clear spaces in:,ide the garage?
Is privacy protection planting required for the project? Y ON
On what floor(s) is work being done? Jle—coo (
Brief description of work. cle,Q Z.d ��o MY kra It
Code editions:2008 CBC N)2008 CFC (Y---)N)2008 CMC (VN)
2008 CPC N)2008 NEC -N)
t�r-'rr<V V r_U
Effective 1AMDANCE WITH THE CITY Of
,UPOMNO CODES AND ORDINANCES
ATE 1/"- 3 �.,�.�. SHEET
B I
IGNEL
his set of cions Mus'!
kept on l And it is ur.
1wful to ma;114 : c)r alteration
n same w:.;. mission fror,
re building
v stamping c ;j specification
HAU NOI be het! ; i, imt or to be ar
NVMI of the viala, ;n ui any provision
. �S c4��sfsrn �2aYA l a,,r
Plan Review Process Work Book Page-B-Revised 1/1/08
112 Bath Remodel
1119 Hollyhead Lane, Cupertino, CA
Overview: Conversion of existing closet space to 1/2 bath.
3 new interior walls to be added with 28" pocket door.
1/2 bath adds toilet, pedestal sink, overhead vent fan &
light, GFCI outlet, and switches for fan & light.
No Structural Changes New Interior Walls
31„ x 4 space for
pre-exisiting vent pipe
0
® F 1
r
Existing 2nd Floor Bedroom
LO
N th
O
O
N 3.
14'10
RESIDENTIAL PROJECT COVER SHEEN.
Assessor's Parcel Number: 6d -26 OIS
Name of owner. Jeri
Project address. ///9 o llu head LW-42 -h ho , C , 9S-0!`f
Contact person. Phone. 4O 8— P3 " Lf 9-0
Fx,. 6 93 - 33.2
Net square footage of lot.
Existing Proposed
Square footage: First floor: /I 0 //170 no 912
Second floor: rw
Garage:
TOTAL: zo Is
Are there at least two 10 foot by 20 foot clear spaces in:ide the garage? N /\/O /9,x 2,
. I
Is privacy protection planting required for the project? Y ON
On what floor(s) is work being done? J2c�✓�d rl�c�'
Brief description of work. k-,M0 o a e.� Z�d ��� o !Z � r n M
Code editions: 2008 CBC ( N)2008 CFC (Y2 N)2008 CMC N)
2008 CPC N)2008 NEC -N)
Effective 1/1/08
'ado
ss�ss
d
Plan Review Process Work Book Page-8-Revised 1/1/08