12080204 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 937 COTTONWOOD DR CON"IRACfOR: PERMIT NO: 12080204
OWNER'SNAME: NABF,R RAVEN KA — blk15JflJJ C�I J 4DATF ISSUED:08202012
OWNER'S PlIONE: 6502189979 PHONE NO:
❑ LICENSED CON"I'RACfOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUNIB r
License Class Lie.0p1
94 39 r
T � ECli r RESIDENTIAL r' CONINIERCLU.
Contractor V_N ` C nf1ln�li-%Date-9 12-0 1 7,0 12-
1 hereby alfimn that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ROT REPAIR,REPLACE ONE SHOWER,COPPER REPIPE,17
(conrnencing with Section 7900)of Division 3 of the Business&Professions NEIL'CAN LIGII'I'S,REPLACE ALL DOORS AND WINDOWS
Code and that my license is in full forceand nd effect.
1 hereby affirm under penalty of perjury our of the following two declarations:
I have and will maintain a cenifmcate of consent to self-insure lar 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 r�
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of ilte work for which this Sq. Ft Floor Arca: Valuation SL37 �g
permit is issued. wGi 9 hhhppJ`S.1 t�h'i
.U'I'LIC.\N'1'CP.R'I'I FIC,\TION ANN Number:36917044.00 A , �wbceti0anc�"hre:�
I certify that I have read this application and state that the above information is {+,� Sk c
correct.1 agree to comply with all city and county ordinmmcs and stale laws relating vcc'� �`"ll F\ I
to building construction,and hereby authorize representatives of this city to enter V
upon lheabove mentioned property for inspection purposes. (We)agree to save PERMIT°GXI'I RESZ WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities.judgments, n u4
costs,and expenses which may accrue against said City in consequence of the WITH IN480)DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands mid will comply 1
with till non-point source regulatiatsper the Cupertino Municipal Code,Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18. ^D
r
Signature Datcjfld2 X12 Issued by: \L__7
.� Date:
❑ OWNER-BUILDER DECLARATION
RE ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law fur one of All roofs shall be inspected prior to any roofing material being installed If a roof is
the following two reasons: installed without first obtaining am inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole coniNnsation. inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business S Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business l Professions Code). ALI,ROOF COVERINGS TO BE CLASS"A"OR BEITEIR
hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's IIA%ARIIOUS MATER1A1 S DISCLOSURE
Compensation;as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued California Health S Safety Code.Sections 25505,25533,and 25534. ]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 Health S
Section 3700 of the Labor Code,for die performance of the work for which this Safely Code.Section 25532(x)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. Contaminants as defined by the Bay Amo Air Quality Management District I will
I certifv that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino)lunicipal Code.Chapter 9:12 and the
not employ any person in any manner so as to become subject to the Worker's Health S Safely Code,Sections 25505,25533,and 25534.
Compensation laws of Califomia. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner o uthorize ag it-
forthwith
tforthwith comply with such provisions or this permit shall be deemed revoked lr�, Date'
A I'll LIC\NT CERTIFICATION CONSTRUC711ON LENDING AGENCY
I certify that I have read this application and state that the above infommtion is I hereby alliin ihm there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances mid 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 property 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 ARCHITECT-S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Dale Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 937 Cottonwood Dr. DATE: 08/20/2012REN'IEWED BY: jsg
-A PN: BP#: 'VALUATION: 1$13,700
*PERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY 2nd Unit? Yes No PEN"1'ADLl9'ION
USE: SFD Of Duplex OTC? O Yes
(D No PERMITTYPE:
WORK Rot repair, replace one shower, copper re i e 17 new can lights, replace all doors and windows
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE 11) BP FEES BP FEE ID
CONSTR. (s.L)
R-3 (Custom) n-B,111-B,IV,V-B 0 $0.00 $0.00
L= T
TOTALS: 0 $0.00 $0.00
MECH, HOURLY O Yes G No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY Q Yes Q No
Mech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check 0.0 hrs $0.00
Meeh. Permit Fee: Plumb. Permit Fee: IPPERAHT Elec. Permit Fee: IEPERcbIIT
Other,tfech./nap. Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Insp. 0.0 hrs $45.00
Me& Grey. Fee: Plumb. /asp. Fee: Elect Insp.Fee:
NOTE: This avdin ate docs not includeJee+'clue u,other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). These feev are hosed on the prehininarl information availahle and are onh,an estinute. Gunact the De I or addn'l info.
FEE ITEMS (Fce ltesohtion /1-053 T_B: 7/1//1) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Plumbing
Suppl. PC Fee: (2) Reg. O OT 0.0 hrs $0.00 $10.00 IBPPIA7URE I Fixture set on One Trap
PME Plan Check: $0.00 1 # Plumbing
Permit Fee: $0.00 $13.00 /PRREPIPE Re-Pipe Interior
Stipp]. Insp. Fee:Q Reg. Q OTF-01hrs $0.00 17 Electrical
PME Unit Fee: $0.00 $67.00 /BREMFLl7 Fixtures, Lighting
PML' Permit Fee: $90.00 = # Window/Sliding Glass Door
Consnvtction Tax: T $533.00 I11'1NREP Replacement
Administrative Fee: O
Work Without Permit? O Yes Q No $0.00 G
Advanced Planning ["cc: $0.00 Select a Non-Residential t7
Travel Documentation Fee: ITRA VDOC $45.00 Building or Structure O
i
Strong Motion Fee: IBSEISABCR $1.37 Select an Administrative Item
131dg Stds Commission Fcc: IBCBSC $1.00
SUBTOTALS: $137.37 $623.001 TOTAL FEE: $760.37
Revised: 07/01/2012
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
GUPERTINO (408) 777-3228• FAX (408) 777-3333• building(a)cuoertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORICINALPERMITN
V PROJECT ADDRESS D �1 APNN — 1 -
XOWNERNAME1 PHONE tO„^—^) r EMAIL
/ STREET ADDRESS I �- c'7 M01VjvL1�' ••�\\M�1 . CITY, STATE,ZIP
CONTACT NA E PHONE EMAIL
/S�TTRI�EET ADDRES --L Y CITY,STATE ZIP FAX
}'1UWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME LICENSENUMBER LICENSE TYPE BUS.LICA
�e Sa oI� y 3
COMPANYNAME I Co C o^ E-h1AIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE `.
p3 MAS 2� (��t.1 , c ) 1. Yo ) - z,
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC 4
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE
DESCRIPTION
�TOF.WORK
S I 'L � S��- �Ar \`�\�rw• 1 Gh.iTO c�.0 G� ISE�I P! _
vAa re P'Jp eu -Iber a-.c1 Sc,L- YI- Ce-c-, r,TY
EXISTING USE PROPOSED USE CONSTR.TYPE 0STORIES UU
USE TYPE OCC SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA I DECK AREA TOTAL DECIUPORCH AREA GARAGE AREA: DETACH
❑ATTACH
a DWELLING UNITS: IS A SECOND UN'I'T ❑YES SF.CON'DSTORY C]YES
BEING ADIWDT DNO ADDITION' DNO
PRE-APPLICATION OYES IF YES,PROVIDE COPY OF IS I HE BLDG AN DYES RECEIVED BY- TOTAL VALUATION:
PLANNINGAPPLO []NO PLANNING APPROVAL LETTER EICHLER TIO?IE• 0N ✓'-
_ _ Q
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and State laws relating to uilding constmetio . auth rize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicanJAgeni: Date:
SUPPLEMENTAL INPORNIATIONREQUIRED _ PhANciu:cH�i'ri�e .ROUTINGSLIP
New SPD or Multifamily dwellings: Apply for demolition perrnit for Cl. ovI>H=nuxouN'I'1: ❑ Buu.gmc r1:ANArivIF:YY
existing building(s). Demolition permit is required prior to issuance of buildin -
permit for new building. .❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑'srANDARD ❑-PUBLICN ORBS
Corm if any Hazardous Materials are being used as part of this project. - -
❑ 1„\RC.1: ❑ TTRE IIEPT�
_Copy of Planning Approval Letter or Meeting with Planning prior to _
submittal of Building Permit application. ❑ MAJOR' S,\NITARY'.SEYP I:H UIST'RICT
r
❑-ENVIRON'MEN'TAL HEALI11
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