12070138 CITY OF CU13ERTINO 13UILDING PERMIT
BUILDING ADDRESS: 21836 WOODBURY DR CON PRACIOR:WELKIN INTERNATIONAL PERMIT NO: 12070138
IND INC
ON'NEWSNAME: CHEN SAMUEL C AND THERESA K 20731 DANFORD DR DATE ISSUED:07/172012
OWNER'S PRONE: 4083943628 CUPERTINO.CA 95014 PI[ONE NO:(408)888-9096
❑. .i LICENSED COM'RACI'OR'S D EICCLA��RA�TIION BUILDING PERMIT INFO: BLDG [ ELECT r PLUMB r:
License Class Lie.N 2-620
� I\IECI1 r RESIDENTIAL r COMMERCIAL r
Contractor / Ct/ /�Lf2! L/To� Date
JOB DESCRIPTION: LEGALIZE BATBROOhI REMODEL
hereby affirm that I am licensed under the provisions of Chapter 9
--SEE NOTES--
(Commencing with Section 7000)of Di%ision 3 of the Business& Professions
Code and that my license is in full force and effect.
hereby affimn under penalty of perjury one of the following Iwo 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
perfommnce 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:$3500
Section 3700 of the Labor Code,for the performance of Ore work for which this
pcnnit is issued
\I'N Number:32619070.00 Occapanep'I'ype:
AI'PLIC,\N'I'Cfaf1'IPICA'I'ION
I certify that I have read this application tad 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 ollhis city menter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the 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 t
graining of this permit. Additionally,the applicannunderstands and will comply, 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by]�� Date.
Signature _ �� Date
❑ OWNER-RUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the follow ing nvo reasons: inspection.
I,as owner of the property,or any employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sce.7044, Signature of Applicant: Date:
Business S Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business& Prolessions Code). ALI,ROOF COVERINGS TO BE CLASS"A"Olt RE'l'I'ER
hereby affirm under penalty of perjury line of the following three
declarations: IIAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate ofConscnl to self-insure for Worker's I lire read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health S
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code.Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
pemnil is issued. contaminants as defined by the Ray Arca Air Quality'Management District 1 will
maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the performance of die work for which this permit is issued,I shall Health S Safety'Code,Sections 25505.25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation Imes of California. If,after making this certificate of exemption,I Owner or authorized
become subject to the Worker's Compensation provisions of the Labor Code,I Elitist Due:
Ibrhwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERT'1 FICATION I hereby affirm that there is a construction lending agency for the perfommnce of work's
I Certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Cir C.)
correct. I agree to comply with all city and county 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.(We)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
granting of this permit.Additionally,the applicant understands and will comply ARCH ITI?CI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Profemimu l
Signature Dale
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21836 woodbury dr. DATE: 07/17/2012 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: $3,500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM
USE: PERMIT TYPE:
WORK le alize bathroom remodel for code enforcement case.
SCOPE
Mech. Plan Check Plumb.Plan Chec6 Flee. Plan Check
Mech-Permit Fee: Plumb. Permit Pee: race.Permit Fee:
Other dlech. Insp. Other Plumb insp. Ll I
Other Flee.1rrs7�.
,11ach,Imp.Pee: Plumb. hrrp. Fee: Elec.Insp.rec:
NOTE: This estimate does not include fees slue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School
District,etc.). These fees are based on the prelitninun information available and are only an estinate. Contact the Dept for addm7 in o.
FEE ITEMS (Fee Resolittion 11-053 EfT 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 40 s.f. Remodel, Bath (<=300 so
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $600.00 /REMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. Q OT 0,0 [its $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative Fee: O
Work Without Permit? O Yes 0 No $0.00 G
Advanced Planning hec: $0.00 Select a Non-Residential
Trowel Doctanentaiion Feer: Building or Structure
Strom, Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blds Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $600.00 TOTAL FEE: $601.50
Revised: 07/01/2012
I Z(D- 7
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildino(ccupertino.oro
❑ N EIV CONSTRUCTION ❑ ADDITION Al I'ERATIONINTI ❑ REVISION/DEFERRED ORIOINALPERMITN
PROTECT ADDR•S k1 �JOJl7 P) /A-Y �.: ^ �NO APNq (P 1 _ rte-
OWNER VAMC er V ! �(t, PI R`NP 0$ 31��6 20 E-MAUL f 113
STREETADDRESS C./ CITV', STATE,'LIy FAX
loon LJ bR r..47�w 1 1A 93- el
CONTACT NAMH/ PIIONE E-MAIL
STREETADDRESS CITY,STATE. ZIP FAX
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
ONTRACTOR NAME LICENSENUNIBERLI ENSETYPE BUS.TIC
r74R,12
COMPANYNAAIC E-MAIL FAX
r
STRECTADDRESS CITY:STATE,7.11' f PHONE
1 )/ ! ✓ i o
vrl
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESC IPTION OF WORK
;-z� l3afhRaorrl Pn,ocle�•;r Com e �>l�
EXISTING USE PROPOSED USE CONSTR.IYPC #STORIES
USE TYPE OCT, SQ.FT. VALUATIONS)
EXISTG NEW FLOOR DENIOTOTAL ,r-Y
AREA AREA AREA NET AREA
BATBROOAI (� KITCHEN OTIIER
RatODEL AREA /O - REMODEL AREA RENIODELAREA
PORCHAREA DECK AREA TOTAL DECKWORCHARFA GARAGE AREA: DErACH
C:]ATTACH
#DWELLING UNITS: ISASECONDUNIT OYCS SECUNDSTORY []YES
IIF.INGADDED' []NO ADDIt'ION'. []NO
PRE-APPLICATION ❑V'ES IF YES,PROVIDE COPY OF IS 1111:IILDGAN OYES RECEIVED BY: � TOTAL VALUATION:
PLANNINGAPPL# C]NO PLANNING APPROVAL LETTER EICu LERROMI:'. []NO .4 n COO
By my signature below,1 certify to each of the following: 1 am the property owner or authorized agent to act on the property 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 building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicandAgenD Date: :7h y,L/�
SUPPLEMENTAL INFORMATION REQUIRED PL,\NCmiCKTY'PF. ROUT'hNG SLU'
New SFD or Multifamily dwellings: Apply for demolition permit for
eXisting building(s). Demolition permit is required prior to issuance of building C�3--rtcT:R:nlr:-cousrER III111.DING 1't.\$REVIEW
pennit for new building. ❑ EXPRESS ❑ PLANNING PI,\N REVIEW
_Commercial Bldgs: Provide a completed I'lazardous Materials Disclosure ElSTANDARDElPUHLICw0RKS
form if any hazardous Materials are being used as pan of this project.
❑ 1..\RGr: ❑ FIREDEPT
_Copy of Planning Approval Letter ar Meeting with Planning prior to ❑ \I WOR ❑ SAN'I'I'ARYSENVER DIS'1'RICr
submittal of Building Permit application.
❑ F:N'\'IROSMr1\'T,\L IIF\CI'ii
BIrlgApp_2011.doc revised 06/21/11