12080236 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10930NORTI]SKYSQ CO\1'RACI'OR:KECIIEN PFRMITNO: 12080236
OWNFR'SNAMF-: KECIIEN 1930 NORTI]SKY SQ DATE ISSUED:0822R012
OWNER'S PHONE: 4086219677 CUPERTINO,CA 95014 PIIONF,NO:
❑ LICENSED CO\FRAC'fOR'S DECLARATION •JOB DESCRIP HON: RESIDE TIAL❑ COMMERCIAL
License Class Lie,q BUILD AN INTERIOR WALL,CLOSET,ADD A DOOR, AND
(2)OUTLETS TO CHANCE A DEN INTO A BEDROOM
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9
(conunencing with Section 711(10)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following byo 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. Sq.Ft Floor Area: Valuation:$2000
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
AI'N Number:31640057.00 Occupmhcy'1'ypr.
permit is issued.
nrrl.IcnN'r ceR'ru Icn'noN
1 certify that I have read this application and 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,mid 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 liabilitics,judgmenls, rd - ` '' p 9
costs,and expenses which may accrue against said City in consequence of the Issued b �G/J(v' /7�TGYT Y/' O� /�
gr:mting of this permit. Additionally,the applic:mt understands mid will comply Y o _ Date:
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
I inspection.
❑ OWNER-BUILDER DECLARA'T'ION
Signature of Applicant: Date:
1 hereby:dfirm than 1 am exempt from the Contractor's License 1-taw for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETI'ER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and tire structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Ih\%AItDOUS\LVI'P.R IA I,S DISCLOSURE
construct the project(Sec.7044,Business&Professions Code), I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilcalth&Safety Code.Sections 25505.25533,and 25534. 1 will
I hereby aBlrin under penalty of perjury one of the follmving three maintain compliance with the Cupertino Municipal Coda Chapter 9.12 and the
declarations: Ilcalth&Safety Code.Scetion 25532(a)should I store or handle hazardous
'I have and will maintain a Certificate of Consent to schf-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air conumtinants as defined by the Bap'Area Air Quality Management District
perl'onnance of the work for which this permit is issued will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as s provided for by - the Health&Safety Code.Sections
255505,25533.and 25534. Q
Section 3700 of the Labor Code,for die performance of Elie work for which this Owner or authorized'agent: / Atf��\/ ' Date#36 �z ?vv I;
permit is issued.
I certify that in the performance of the work for which this permit is issued,1 shall
not employ any person in any manner so as to become subject to the Worker's
Compensation Imus of California. ll:atter making this ceni0cate of exemption,I CONSTRUCTION 1,ENDENC AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 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 w'ork's for which this pennit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICAN I'CERTIFICVIION Lender'sAddress
I certify that I have read this application mid 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 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, ARCI11TECI"S DECLARATION
costs,and expenses which may accrue 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 2 Z ZO j'L
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10930 Northsky Sq DATE: 08/22/2012 REVIEWED BY: Sean
APN: BP#: `VALUATION: $2,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PLNI
USE: SFDorDuplex PERMITTYPE: 1R3SFDRE i
WORK Build an interior wall closet add a door, and 2 outlets to change den into a bedroom.
SCOPE
dlech. Plan Check Phonb.flan Check Dec.Plan Check
Alech. Permit Fee: Plumb.Permit Fec: Glee. Permit Fee:
Other Alech.layp. Other Plumb Insp. Other Elec.Insp.
Ale.ch. ln,,p. Fee: Phonb. hist.Fee: Elee.Insp.Fee:
NOTE: This eviinmte does not includejeev clue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sever District,School
District, etc.). These feav are based on the prelintinan•information available and are on&as evtimnte. Contact the De t or addn'I info.
FEE ITEMS (Fee Resohaion 11-053 Eff 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = s.f. Remodel,Other
Suppl. PC Fee: Q) Reg. O OT 0,0 hrs $0.00 $400.00 IREAIRESOTH
PML' Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Contraction Tax:
Administrative Fee: _ 0
Work Without Permit? O Yes (D No $0.00 E)
Advanced Planning Fe(: $0.00 Select Non-Residential E)
Travel Documentation Fees: Building or Structure 0
A
Strong Motion Fee: IBSF.ISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $400.00 TOTAL FEE: $401.50
Revised: 07/01/2012
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CONSTRUCTION PERMIT APPLICATION Cap AUJ
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333•buildinga()cupertino.org
CUPERTINO %�7op ,ta
❑NEW CONSTRUCT ION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEPERRED ORIGINALPERMITN
PROJECT ADDRESS 0 / O n'O✓, I Sk 5 ' E5OI/1- APN/H 7Q&/ - 0- D{�"// �j�f I -- _,�
OWNER NAME Ke C /e ,,, �I•) PHONE 4PST -6-z( -967 7 E,-'pTIAAIIL ✓ /� /LON'&4• CA
S'1'REEI'ADDRESS 10930 /I,Ort�S,j 71 ,9 CITY, STAI'f 7.IP CtEr --I`nom n A J5'0Jq- FAX
CONTACT NAMEye. C4UA' PHONE 408 424 � `�7 / E-MAIL
STREETADDRCSS 77�`30 /U�rE�Sk 5 CITY•s'rATE, ZIP YO n�Aff'.Ano' (�44 Q^O`�L FAX (,
OWNER ElOR:YERAUILDER 13OWNERAGENT ElCONTRACTOR 11CONTRACTOR AGENT ❑ ARCHfmcT ❑ENGINEER ❑ DEVELOPER ❑ T&NANf
CONTRACTOR NAM I LICENSE NUMBER LICENSE TYPE BUS.LIC 9
H�
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE ZIP PHONE
ARCHITECT/ENGINEERNAML' LICENSENUMBER BUS.LICq
COMPANY NAME. E-MNL FAX
STREET ADDRESS CITY,STATE ZIP PHONF.
DESCRIPTION OF WORE:
To 6;Id wa.fl a dwr of a -{o S l t 6t kei&mn
IiXISTING USE PROPOSED USE CONSnt.TYPE usTDRIFS
D �2//1E /✓ O//SL' V� USE TYPE OCC. $O.IT. VALUATION(S)
EXISTO NEW FLOOR DEMO TOTAL ,V5
AREA AREA AREA
BATHROOM KITCHEN OTHER
REAIODEI.AREA REMODEL AREA REMODEL ARuA/aQ
YORCfl A0.E\ DECK AREA TOTAL DECKWOKCH AREA I GAKAOEAREA: LJDETACII
0ATTACH
O DWELLING UNITS: IS A SECONEIIISIT [3 YES SECOND STORY OYES
RF.INCADDEDT 090 AUDI'rI"; 12M1O
PRE-APPLICATION 1]YES IF YIS,PROVIDE COPY OF IST'IIEm.UGAA' ❑YS RECEIVED 3Y _ TOTAL VALUATION
PLANNING APPL/�NO PLANNING APPROVAL LEITER EICHLER HOME? 10 1 1 ��/ +. � LPO
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 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 Applicant/Agent: Date: Da/2-2-j 12-
SUPPI,CM11hN'I'nl. INFORMATION REQUIRED -''
�r1AN cni:ci:-r\T'e Ro11TfNc si,ih
New SPD or Multifamily dwellings: Apply for demolition pelntit for 'T pYF:H=I'll f2CoIJNi'F:R 1•, .�Iiu H.li1N'f.PIAN REVIEW
existing building(s). Demolition pennit is required prior to issuance of building T_ LL - •d. .
permit for new building. ❑ r: raFss ❑ PL%SNIN'G PLAN REVIEW
fR. .. .1.
Commercial Bldgs: Provide a completed I'larardous Materials Disclosure '❑ SFAND\RD , ❑ PUBlucwoRKS
f_orm if any I lazardous Materials arc being used as part of this project. EJ
'iei3GE El dlRenlirr,
_Copy of Planning Approval Letter or Mecting with Planning prior to MAJOR ' - ,❑'SANITARY SF.N'F._1RD1STRICT'
submittal of Building Permit application. -
. ❑ ENYI RIIN,MENTAL IIEAIAIf
13/dg.4pp_201 l.doc revised 0612///1