12080317CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10239 PALO VISTA RD
CONTRACTOR: LUU CONSTRUCTION
PERMIT \0: 12080317
INC
OWNER'S NAIV E: TAMBE ATUL A AND ROI IINI A
333 AVENIDA PINOS
DA'Z'E ISSUED: 08/30f2012
OWNER'S PHONE: 4083164436
SAN JOSE, CA 95123
PI IONE NO: (408) 623-7558
LICFNSED CON'IRACI'OR'S DECLARATION
JOB DESCRIPTION: RESIDEN"FIAL 11 COMMERCIAL
License Class Lie.9 BG% i 7L
REMODEL BATHS 187 SQ FT
/
Contractor 5G(� L(.?-LA Date e o I—
I
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing wilh Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I
1 hereby affirm under penally 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
Sq. Ft Floor Area:
Valuation: $18000
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 35701072.00
Occupancy Type:
APPLICANI' CFRTIFICA'TION
I certify that 1 have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 1 DAY$ 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 DAY ROM ST CALLED INS P CTION.
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
Issued by: Date:
with all non-point source reg i s per t upertino Municipal Code, Section
9.18.
RE-ROOFS:
Signature Date L
All roofs shall be inspected prior to any roofing material being installed. If a rooris
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
❑ OWNF-R-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BET'T'ER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, andthe structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
IIAZARDOUS MATERIA S DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
llenith & Safety Code. Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent 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
performance of the work for which this permit is issued.
will maintain compliance with the Cupar' o Mynicipal Code, Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance, as provided for by
the Ilealth &Safety Code.Sections 2 2 3, and 25534.
Section 3700 or the Labor Code, for the performance of the work for which this
Owner or authorized ngent:. C Dale: (..
permit i5 issued.
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 of exemption, 1
CONSTRUCTION LENDING AGENCY
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
APPLICANT CER'T'IFICATION
Lender's Address
1 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,
ARCHITECT'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
CITY OF CUPERTINO
1►Yr��.S//I FEE ESTIMATOR—BUILDING DIVISION
L.
ADDRESS: 10239 palo vista
DATE:
REVIEWED BY: bobs.
blecb. Permit ree:
APN:
BP#:
'VALUATION:
$18,000
*PERMIT TYPE: Building Permit
PLAN CIIECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
F.lec. Insp. Fee:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
sfd remodel 3 bathrooms non structural.
SCOPE
$0.00
NOTE: This estimate clues not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary So,,er District, School
Distrirt. etc 1. These lees are based on the nreliminan, information available and are only an estinuae. Contact the Dent for addn'I info.
FEE ITEMS (Fee Resolution 11-053 E/f i/l/ll)
Mech. Plan Check
Plumb. Plan Check
Elec. Plan Check
blecb. Permit ree:
Phmrh. Permit Fcc:
rlec. Permit Fee:
Other• Alech. Insp.
Other Plumb Insp.
Other F -Ice. Insp.
Alech, hc,p. Fee:
Plumb. hrcp. Fee.:
F.lec. Insp. Fee:
NOTE: This estimate clues not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary So,,er District, School
Distrirt. etc 1. These lees are based on the nreliminan, information available and are only an estinuae. Contact the Dent for addn'I info.
FEE ITEMS (Fee Resolution 11-053 E/f i/l/ll)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
187 s.f.
$600.00
Remodel, Bath (<=300 sO
IREAIRESBAT
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -.0 Reg. 0 OTT-OOThrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tay:
Administrative Fee:
O
0
Work Without Permit? O Yes 0 No
$0.00
Advanced Planning ['cc:
$0.00
Select a Non -Residential
Building or Structure
0
Q
A
Travel Docamenuuion Fees:
Strong Motion Fee: IBSEISAIICR
$1.80
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$2.80
$600.00
TOTAL FEE:
$602.80
Revised: 07/01/2012
CONSTRUCTION PERMIT APPLICATION
�.,'1�..�/�7� COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
II��u�f•`11I 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
ERTIN
IC�IUP910 (4088)777-3228 • FAX (408) 777-3333 • build�iinnIdcDcupertino oro
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CUNIRACIDR ❑ CONTRACTOR AGEM ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER 11 TENANT
CONTRACTOR NAME
LICENSE NUMBFA /
LICENSETYPE
BOS.IACP
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LICENSE NUMBER
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COMPANY NAME
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1
DESCRIPTION OF W(ARK f }i IGS
IhgtlE� Bn>t1\ •. 2e LI'1� sf r .S Wer inskt 1 c
Mn+Far Vgr.tl Z <1g11 �+ sT^ �• p� o nilRsl G.6i iry, MOVIE SINKS b
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Va."fi(y)a it.\ V i:UZJ<1 In<If,II TAW Tq�ltisl T`K1 I Ia I4'fcleT
EXISTENG USE
PROPOSED USE
CONSTR TYPE
PMKIES
SLI
Cel
2,
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
ANISIC
AREA
NEWARUA OR
ARCA
DENIOAREA
AREA
NETAI.
NET AREA
S
DATHRODM, KnrcI CIPHER
REMODFI. AREA 'S'7 RETIOnn AREA RI:MODELARFA
PORCH AREA DECK AREA TOTAL DECK/PORCII ARF( GARAGEARFV
BOIDACD
ATTACH
pN'EWNG UNITS:
AA SECOND UNF f]YIS
SECOND STORY OYES
9EING ADDED! ONO
ADDITON, ONO
PREAPPI.ICATON OYES IFY6,PROVIDECOPYOF
LSTUEDLOCAN OYU
RECEIVED BY:
TOTAL VALUATION:
PLANNDNGNPLY ONO PIANNWG APPROVAL I.ETD'A
EICHLEI IIOMET ONO
� D �j\
By my signature below, I certify to each of the followin : I am the property owner or authorized agent W act on the property owner's behalf. I haveread this
application and the informution I have provided is C t. I ha read the Description of Work and verify it is aceumte. I agree to Comply with all applicable local
ordinances and state laws relating W buildi Ca Ion �uthorim representatives of Cupertino to enter the above-idrntifed property for inspection purposes.
Signature oFApplicant/Agenc Date:
SUPPLEMENTAL INFORMATION REQUIRED
PIAN CHECK TYPE
SLIP
`CI'OVER-TTIE.C(/[INT'ER
��ROUTING
UL'f5npsnc PLAN REVIEW
_ New SPD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition pe trait is mquirred prior to issuance of building
permit for new building.
❑ EXPREss
❑ PLANNINGPLANREVIEw
Commercial Bldgs: Provide a Completed Hmandous Materials Disclosure
❑ SrANDARO
❑ PUBLIC WOIULN
form if any Ilaza dour; Materials are being Used as part of this project.
❑ LARGE
❑ FERE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARYSEWERBTS1711I471'
submittal of Building PerTnit upplication.
❑ ENVIRONMENr'ALIIEALTB
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