12080168 i
CITY OF CUPERTINO BUILDING PERMIT
Bl11LDING ADDRESS: 1478PRIMROSE.-WAY CON'I'RACI'OR:SEARS HOME PERMIT NO: 12080168
IMPROVEMENT
O\\'NER'S NAME: GREGORY KENTA ET AL 1024 FLORIDA CENTRAL PKWY DA'Z'E ISSUED:08/152012
OWNER'S Pl IONF-: 4082572294 LONGWOOD,Fl. 32750 PHONE NO:(925)245-2000
hj) LICENSED CONTRACI'OR'S DECLARATION .1013 DESCRIPTION: RIiSIDENPIAL❑ COMMERCLU.11
License Class C10_/_) 6G Lie.4 '721 379 MINOR KITCHEN REMODEL TO INCLUDE PLUMBING
/ / (KITCHEN
Contractor Not1f IWID Doe 5 �Z SINK/FAUCET/DISPOSAL)AND ELECTRICAL(ADD 2
1 hereby affirm that I am licensed un�prnrisiuns of Chapter 9 OUTLETS), REPLACE 5 OUTLETS AND(1)TWO CIRCUIT
(commencing with Section 701111)of Division 3 of the Business&Professions
Code and chit nw license is in full force and effect.
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 Ibis permit is issued Sq.FI Floor Area: Valuation:$18782
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this
.\IiN Number.36615020.00 Occupanq'I'ypc
permit is issued.
AI'I'LICA\I'CER'I'I PIG\'PION
1 cenity that I have read this application mid state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, //
costs,and expenses which may accme against said City in consequence of the Issued b ��/w�/�� Date: GL'
granting of this permit. Additionally the applicant understands mid will comply y: /
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18,
RE-ROOFS:
Signature Date / 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 new materials for
inspection.
❑ DECLARATION 11LUIiR -11LUlilt -
Signature of Applicant: Dam:
I hereby affirm that I am exempt from the Conlractor's License Law formic of
the following two reasons: ALL ROOF COYF-RINGS T'O BE CLASS"A"OR RF-T FER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the stricture is not intended or offered for sale(See.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to I IA"/-AFI DOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California lle:dlh&Safety Code.Sections 25505.'_5533•and 25534. 1 will
I hereb\ affirm under penalty of perjury line or the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: health&Safety Code.Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consnu to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the .air contaminants as defined by the Bay Area Air Quality Management District 1
performmnce of the work for which this permit is issued. swill maintain compliance with the Cupertino;Municipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the I lealth&Safely Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this n 5
Owner ar.authori'reJ agar: Date:
permit is issued. 1S
I certify 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 Worker's
Compensation laws of California. If,,after making this certificate ofexemption,I CO,N&144 ON LENDING AG. NCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
\I'1'I-IC,\\I'CF;R'I'IFIC,\'I'111N Lender's Address
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 aid state laws relating
m building constriction,and hereby authorize reprcscntatives 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, ARCIIITFC`I S DECLARATION
costs,and expenses which may accme against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION I P
Ell COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 I �1 ^
CUPERTINIO�-�(( (408) 777-3228 • FAX(408)777-3333 • burrilldrd{{inD(a.cupertino.orD y��7v\ ■7v�J_
E PLUMBING ❑MECIiANICAL 1[y ELECTRICAL ^, ❑MISCELLANEOUS 080/&"
PROJECT ADDRESS / �1(j �21 n� I AP\k �/,.," /S maw
OWNER NAME / b C_ (�� PHO E •1,4 E-MAll.
�A-7szlct/a G iz<<v,`� �oST� z5� ' 7—Z C1,4
STREET ADDRESS '^ �ZIy1'1 R0 CITE SATE.ZIP C d - FAX
CONTACT NAME BERNIE MATHESON PHONE925-245-2013 �1 E-MAIL
STREET ADDRESS CITY.STATE. ZIP FAX
283 E. AIRWAY BLVD. )X(..,, LIVERMORE,CA 94551 925-245-2017
13 OWNER ❑ OWNER-BUILDER 13OWNERAGF.NT LJ CONTRACTOR ❑CONTRACTORAGENr ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICE.NSENUMBF.R 721379 LICENSE TYPES,CIO BUS.LICA
BERNIE MATHESON C37 C6
COMPANYNAME SEARS HOME IMPROVEMENT EMAIL FAX 925-245-2017
STREETADDRESS 283 E. AIRWAY BLVD. CITY.STA7'L'.ZIPLIVERMORE, CA 94551 PHONE 925-245-2013
ARCHITECG6NGINEER NAME LICENSE NUMBER BUS.LIC a
COMPANY NAME E-MAIL FAX
STREETADDRESS CITY,STATE.ZIP PHONE
USE OF �SFDrnDUPLEX ❑ MULTI-FAM707 PROIECr IN WILDLANU El VES PROJECT IN [I YES IS THE BLDG AR ❑ YESBUILDING. ❑COMMERCIAL URBAN INTERFACE A0.EA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME' ❑ NO
DESCRIPTION OF WORK IV !J I
Inl Z I'7GHe TJ f'"rMI IN A-J E)c" _-7121
TOTAL VALUATION: ' ?Q `L 0-0RECEIVED BY:
JE/1�
By my signature below,I certify to each TTofJf the following: I 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 represe pertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: R�� 5 r7—
RUPPLEMENIAL-NIF:PRMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNT ER
❑ EXPRESS
1
u
❑ STANDARD
u
❑ L,.ace
❑ MAJOR
A1EPA1iscd pp_20//aloe revised 0612//l I
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 1478 Primrose Way DATE: 08/15/2012 REVIEWED BY: Sean
.21 APN: BP#: `VALUATION: $18,782
*PERMIT TYPE: Building Permit PLAN CIIECK TN,PE: Alteration / Repair
PRIMARY SFDorDuplex PENTAMATION 1RPK
USE: PERMITTYPE: '4
WORK Minor Kitchen Remodel to include plumbing (kitchen sin k/faucet/dis osal and electrical add 2 outs
SCOPE replace (5) outlets, (1) two circuit upgrade).
A/ech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check 1 0.0 1 hrs $0.00
Afech. Permit Fee: Plumb. Permit Fee: IPPERMIT Elec. Permit Fee: IEPERA11T
Otherafech.Insp. Other Plumb Insp. E hrs $45.00 Other Elec. Insp. 0.0 hrs $45.00
Mesh.buy. Fee: Plumb. Lisp.Fee: Elec.Lisp, Fee:
NOTE-: This estimate does not inchule fees thie to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School
District. etc.). These eev are baser/on the prelintinan in onnatian available and tire onit,an estintale Contact the De t or aildn'l into.
FEE ITEMS (Fee Resolwion 11-053 E!l 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
SuppI. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $10.00 IBPFIXTURE I Kitchen Type System
PME Plan Check: $0.00 7 I Electrical
Permit Fee: $0.00 $45.00 IBREAIRECEP Recep/Switch/Outlets
Supp]. Insp. Fee@ Reg. Q OT F0.0 rhrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $90.00
Construction Tax:
Administrative Fee: I DAILv $42.00 O
Work Without Permit? 0 Yes (F) No $0.00 E)
Advanced Plannine Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRA vDOC $45.00 Building or Structure Q
Strone Motion Fee: IBSEISMICR $1.88 Select an Administrative Item
Bldg Stds Commission Fee: IRCBSC $1.00
SUBTOTALS: $179.881 $55.001 TOTAL FEE: $234.88
Revised: 07/01/2012
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Aug 07 12 09:30p Lawrence de Lara (925)373-6753 p.17
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