12070156CITY OF CU13EIlTINO BUILDING PERMIT
ItUll-DING ADDRESS`: 23500 CIUsTO REY DRUN [T 210C CONTRACTOR: BAY AREA ENTERPRISE PERMIT NO: 12070156
OWNER'S NAME: TAPSON, GLORIA A TRUSTEE & ASSIGN 2110 MANGIN WAY DATE ISSUED: 07/192012
O\PNER'S PIIONE: 6509440118 SAN JOSE, CA 95148 PI ZONE NO: (408)238-5043
❑ LICENSED CON 1'RAC'FOSR'/SDECLAlb\TION BUILDING PERMIT INFO: BLDG r ELECF r PLUMB r1
License Class1" _- -Lie.0 041 l-r�� 1 r r r
1•IECIi RESIDEN'TWL CO\LYIERCIAL
Contractor '.849 k �.Fn {— Date
hereby it ffirm l hat l am licensed under the provisions of Cha pier 9 •JOB DESCRIPTION: UNIT 2100 -INSTALL NEWTUB/SfIOWER
(commencing with Section 7000) of Division 3 of the Business S Professions
Code and that my license is in full force and effect.
hereby affirm under penally of perjury one of the following lyo 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 perfomnance of die work for which this
permit is issued.
APPLICANT charrurlc,rrlcrN
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 sone lasts relating
to building construction, and hereby authorize representatives oflhis city to enter
upon tine above mentioned property for inspection purposes. (We) agree to Save
indemnify and keep harmless the CrCupertino against liabilities, judgments,
costs, and expenses which may ac against said City in consequence of the
granting of this permit. Addiiio I y, the applicant understands lard will comply
with all non -point sours r cul lions per the Cupertino Municipal Code, Section
9.18.
Signature DateN
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lira 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 oDcred for sale (Sce.7044,
Business R Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business R Professions Code).
I hereby affirm minder penally of perjury one of the fallowing 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 fonrhich this permit is issued, I shall
not employ any person in try manner so as to become subject to the Worker's
Compensation lases of California. If, a0er making dais cenitic;de of exemption. 1
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deenwd revoked.
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
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 non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
Sq. Ft Floor Area: Valuation: $750
AI'N Number: 34253044.00 1 Occupancy Type.
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Da / -1,
RF. -ROOFS:
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 nor materials for
inspection.
Signature of
ALL ROOF COVERINGSTO ISE CLASS "A" OR BE'l-FFR
IIAZARDOUS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California I Iealth S Safcl' Code. Sections 2550.5, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health 3
Safety Code, Section 25532(a) should 1 .store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
cantmnimmlts as defined by the Bay Area Air Quality Management District 1 will
maintain compliance %lith the Cupertino Municipal Code. Chapter 9.12 and the
leahh S Sal ty Co .Sections 25505,25533,and 25534.
IF
On'ner nr r 10 ag
Bate, O
CONS'TRUC` IONLENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of ssork's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECI"S DECLARATION
I understand my plans shall be used as public records.
Licensed I'rufessiunal
�� CITY OF CUPERTINO
I�Yr�_y//I FEE ESTIMATOR -BUILDING DIVISION
b&DDRESS:
23500 cristo rey dr. 210 c
DA'Z'E: 07/19/2012
REVIENVED BY:
Meeh. Penna ree:
PN:
BP#:
'VALUATION:
$750
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD Or Duplex
USE:
Elee. Insp. Pae:
PENTA�IA"PION
PER,NITTYPE: A
WORK
install new tub/shower.
SCOPE
NOTE: This estimate doev not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Server District, School
District, etc.). These Amv are based on the nreliminan' information available and are onh, an estinurte. Contact the Dept for at/tbn7 info.
FEE ITEMS (Fee Resolution 11-053 Ell' i/)/ll)
,Rech. Ilan Check
Plumb. Plan Check
Elec. Plan Check
Meeh. Penna ree:
P!„mh. Permit Pee:
flee. Permit ree:
Other Aleeh. Insp.
Other Plumb Insp.
Other Elec. Insp.
hlech. Insp. ree:
Plumb loy)). Fee:
Elee. Insp. Pae:
NOTE: This estimate doev not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Server District, School
District, etc.). These Amv are based on the nreliminan' information available and are onh, an estinurte. Contact the Dept for at/tbn7 info.
FEE ITEMS (Fee Resolution 11-053 Ell' i/)/ll)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. O Ol
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly OnIY? (j) Yes O No
$0.00
Suppl. Insp. FeeQ Reg. O OT
0.0
1 Ins
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax
Administrative Fee:
O
G
Work Without Permit? O Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
= hours Inspections
$266.00 /STavSP Inspection, Hourly
0
0
Travel Doctunentatinn Fear:
Suong Motion Fee: IBSEISABCR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$266.00
TOTAL FEE:
$267.50
Revised: 07/01/2012
I
12-cD-7
CONSTRUCTION PERMIT APPLICATION
COMM UN ff Y-u-P�V:-:LCPMcN'-TE.M.ARTMEI\IT - BUILD ING r--P,:SiON
10300 TORRE AVENUE - C-UPE�RTINO. CA 950143255
(408) -in-3228 - FAX (408) T77-3333 - b0idinc(rZmmertinc.cm
CUPERTINO
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�"�crcrl 'gent w — m -mv=-y o 's be-rmlf. 1 have mad dis
applicalion and the h0brmation I have p�iided is etC.eC rltw-c. adcheDcs=iu.dmofWo&and ,c:ify^3� [a3r=wmn:P1ywith aflamoIiczb1,t,,fl
w!yaiIdigc=rr=m Ve- wcery omposes.
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SUPFLadENTAL WOWAA-flON REQLmAp
nN(ZECKTYPX I ROGMG SE.XP
RVmZwr n�N RmVm[EW
New SFD or Multifimmly dwellings: Apply ror demofizion permit for
=stag bmldiJ�s). Demolition peo jsrw� prior to issues of building
permit for new buRding.
0
0 P"MUNG PTAK REVIEW
CoD>mer .al Bldgs: Disclo are
cl s N'Dwan
0 rubucwcam
form if any Hazardous Matmials arrcb--:�g used as part of zhis mMiecL
0 LARCE
0 FIRS DEPT
—Copy ofPlannin Approval Lena crVatmg m.ith P1mmi29prior tO
C2 MAJOR
01 WNFrr�y ss:� DmrJucr
submittal of Buildmg Permit woUcrfou.
1 0 ErVEROr431&NTALEZLLT33
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