12060160 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11141 CIIADWICK PL CONTRACTOR:-/_V CONSTRUCTION INC PERNIFENO: 12060160
OWNER'S NAh1E: LOCI IHR LEONARD 1 AND AGNES N T 909 SAN RAFAEL AVE DATE: ISSUED:0627/2012
OWNER'S PHONE: 9255849924 MOUNTAIN VIEW,CA 94043 PHONE.NO:(650)213-6512
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class c7 Lie.p R'i6 -
�� MECH r RESIDENTIAL r COMMERCIAL r
Contractor \OVx n.4 4—" . Date 20 I L A
1 hereby'affirm that I lifensed under The provlsion9 oT Chapler9 SOB DESCRIPTION:REMODEL THRGG BATHROOMS.100�QF It�NO REPLACE
(commencing with Section 7000)of Division 3 of the Business&Professions FIXTURES.LIGHTS AND TILE
Cole and That my license is in full force and effect. J.
1 hereby affirm under penally of perjury one of the following Mn declarations:
I have and will maintain a certificate of consent to self-insure for Worker's -Jp
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ollhc work f'or 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 Sq.Ft Floor Area: Valuation:$28000
permit is issued.
APPLICANT CERTIFICATION APN Number:35617079.00 Occupancy Type:
I certify that I have read this application and state that the above information is {'" �' r
correct.1 agree to comply with all city and county ordinances and state laws Eclat ng " lal•i.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for 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 may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit, Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.11. / ) i�f _
Signature Date 6 2 1� Issued by: \ ( Date:V ��
❑ OWNER-BUILDER DECLARATION
RE;ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed If a roof is
the following Iwo reasons: installed without first obtaining an inspection.I agree to remove all new materials for
h as owner of the properly,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant- Date:
L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.70.14,Business&Professions Code), U 1 ROOF COVERINGS TO BE:CLASS"A"OR BETTER
I hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I IAZARDOUS MATERIALS DISCI.OSURF-
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California llealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the llealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(1)should 1 store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued- contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify 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 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 Owner or a ire again • /
forthwith comply with such provisions or this permit shall be deemed revoked-
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above infomtation is I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county 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 properly for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
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-paint Source regulations per the Cupertino Municipal Code,Section ARCIIITF-CT"S DECLARATION
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
I2vloC-)
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 �B
(408)777-3228 • FAX(408)777-3333 • buildinO(ODcuoertino.oro
CUPERTINO
❑YEW CONSTRUCnON ❑ ADDITION ❑ ALTERATION/Ti ❑ REVISION/DEFER.RED ORIGINAL PERM711 #
PROIECI.ADDRESS APNI
i I ac iclL �L •
OWNER;NAMEr Gam- PHONE �?<_ S��_91a E-MAIL.-m-
0. Ir
STREET ADDRESS CITY. STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE. ZIP FAX
❑OwNER ❑ OWN P.BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME lu LICENSE NUMBER —I�� LICENSE TYS HUS.L'CP
–I
COMPANY NAME _ E- FAX
ZJ. i\u - 'l�i.� Z C,msl�l.4c( .
STREET ADDRESSCITY.SI TE. PHONE
ARCHRECr/ENGINEFR NAME LICENSE NUMBER BUS,LC A
COMPANY NAME E-MAD. FAX
STREET ADDRESS CITY.STATE.ZIP PHONE
DESCRIPTION OF WORK3
EXLSTNG USE PROPOSED USE CONSTA TYPE I MSTORIFS
USE TYPE OCC SQFF VALUATION(5)
=TO NEWFLOOR DEMO IIITAL
AREA AREA AREA NEr.AREA
=BATHROOM RTTCHEN OTHER
1%0D LAREA REMODEL AREA REMODEL AREA
I Z
PORCHAREA DECICAREA TOTALDECIVPORCHAAEA GARAGE AREA H DETACH
ATTACH
p DWELI.D+G UNITS: ISASECONDUNTT YES SECOND STORY YES
BEING ADDED? QNO ADDITION. QNO
PRE-APPLICATION ❑YES IF YES.PROVIDE COPY OF MTBEBLDGAN QYFS RECEIVED BY: TOTAL VALUATION:
PLAWKINGAPPLA []NO PLANNING APPROVAL LETTER 9CHLER HOME? [3 NO �t" c?Rv
By my signatum below,I certify to each of the Following: I am the property owner or authorized Agcnr to act un the prpperty owner's behalf. I have read this
application and the infarmation I have provided is cmtenL [have read the Description of Work and verify it is accurate. 1 agree to Comply with all applicable!oval
ordinances and state laws relating to buildingco ct/io9JI authorize represemarives ofCuperdno to enter the above-idrnti5ed ptOperty for inspection purposes.
Signature of Applicant/Agent � - Date:
SUPPLEMENTAL INFORMATION REQUIRED PUN c-pgc-K TYPE - ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTE]R ❑ BDILDING PLAN REVEEW
existing building(s). Demolition permit is required prior to issuance of building -
permitfornewbuilding. ❑ DRESS ❑ PUNNLNG PUN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11STANDARD ❑ PUBUC WORKS
Tom if any Hazardous Materials are being used as part of this project.
❑ LARGE ❑ FIIIE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to -
❑ MANOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑- ENVDRONYMNTAL HEALTH
B1dg4pp_201(.doc revised 06/21111
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 11141 Chadwick PI DATE: 06/27/2012 TRIEVIEWED BY: jsg
APN: BP#: 'VALUATION: $28,000
xPERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Remodel, Bath (300 s.f. max)
PRIMARY Residential PENTAMATION 1R3SFDREM
USE: I I PERMIT TYPE:
WORK Remodel 3 bathrooms replace fixtures lights and tile.
SCOPE
FEE ID FLR AREA
s.f.
1REMRESBAT 100
1/„Jr_ lYun r 'lr,rk /'boob. Ph”,C'4rrA' lilec. PI'm t7rrck
,I l-ch I'rrnril(i " I'Luuh. 1'rrmir Frr: I „r Pw'mir F.•
l7drrr' llrrFi. 1¢ap.
Of/.... !Tomb ln,r'p. 0lhrr 0", hop—El—t-
11 It
op,1-It bly. Fr, Pluurh_ bsep. lire parr_fir.,/'. I4:r:
NOTE: This estimate roes not includejees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prefintina information available and are onl p an estimate. Contact the De t or aildn'l info.
FEE ITEMS (l'ee Rcsolulion I1-053 E/f.' 71/,11) FEE QTY/FEE MISC ITEMS
Plan C,7a01, l'
,Supp!. l'C:Ire:
I'lurn h.:':1 dcr h.%li l rc
Permit Fee: $588.00
Suppl. huh, / 'V
I'l t unhJ:I10 ill,.10cc
1'lumh,%rldrrlr./lilrc l'ermil (ta::
Work Without Permit? 0 Yes 0 No $0.00
All".( 1C,'c1 l'loruMIQ VeCA
from/ Oocuilwwuliwl Fuea:
_S110110Motion Pce: IBSEISMICR $2.80 Select an Administrative Item
131de Sids Commission Fee: IBCBSC $2.00
SUBTOTALS: 1 $592.80 $0.00 TOTAL FEE: $592.80
Revised: 06/30/2012
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JUN 2 7 2012