12030004CITY OF CUPERTINO BUILDING PERMIT_ 0
BUILDING ADDRESS: 19913 LA MAR DR
CONTRACTOR: HUMMEL CUSTOM
PERMIT NO: 12030004
CONSTRUCTION
OWNER'S NAME:
SAN JOSE, CA 95128
PHONE NO: (408) 483-0323
❑ LICENSED CONTRACTOR'S DECLAAR'ATION
T_ r
r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. k 93 3 �
Contractor �L�Q f7�/`��-►FL Date
MECH RESIDENTIAL COMMERCIAL
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: CONSTRUCT 800.9 SQ FT ADDITION AND REMODEL
(commencing with Section 7000) of Division 3 of the Business & Professions
EXISTING 1395.6 SFD AND 441.4 SQ FT GARAGE.
UPGRADE ELECTRICAL PANEL TO 200 AMP. DEFERRED fl -TRUSS CALCS-
Code and that my license is in full force and effect.
9/18/2012 DEFNI 1SS'D
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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
Sq. Ft Floor Area:
Valuation: $200000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 36910036.00
Occupancy Type:
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,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non -point source regulations per the Cupertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date
Issued by: Date:
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1, as owner of the property, or my employees with wages as their sole compensation,
installed without first obtaining an inspection, I agree to remove all new materials for
wiI I do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
permit is issued.
Additionally, should 1 use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued, I shall
contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.I2 and the
Compensation laws of California. If, after making this certificate of exemption, I
Health & Safety Code, Sections 25505, 25533, and 25534.
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of work's
to building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (Sec. 3097, Civ C.)
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Lender's Address
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 19913 LA MAR DR
ACTOR
PERMIT NO: 12030004
OWNER'S NAME:
1 . 1 PHONE NO: I
❑ LICENSED CONTRACTOR'S DECLARATION /
License Class
provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I 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 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.
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.
—9"—/
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, 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 offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I 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
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 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, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed 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
JOB DESCRIPTION: RESIDENTIAL
COMMERCIAL
CONSTRUCT 800.9 SQ FT ADDITION AND REMODEL
EXISTING 1395.6 SFD AND 441.4 SQ FT GARAGE.
UPGRADE ELECTRICAL PANEL TO 200 AMP.
Sq. Ft Floor Area: I Valuation: $200000
APN Number: 36910036.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -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 new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(x) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534. C7
Owner or authorized agent
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
Ill FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS: 19913 La Mar Drive
DATE: 03/02/2012
REVIEWED BY: Sean
PC FEE ID
APN: 369-10-036
BP#: ,Z 03,20 41
'VALUATION: 1$200,000
,PERMITTYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
2nd Unit? Yes No
OTC. 0 Yes ®No
PENTAMATION 1 R3SFDADD
PERMIT TYPE:
WORK
Remodel existing residence 1395.6 sq ft and construct a 800.9 addition
SCOPE
PME Plan Check:
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,111-B,IV,V-B
801
$2,420.00
1R3PLNCK
$1,519.00
1R31NSP
$0.00
PME Plan Check:
$0.00
s.f.
Remodel, Kitchen (<=300 sf)
REMRESKIT
Permit Fee:
$1,519.00
Suppl. Insp. Fee.S Reg.
Q OT
0.0
hrs
$0.00
Remodel, Other
REMRES2
PME Unit Fee:
$0.00
PME Permit Fee:
TOTALS:
801
1 $2,420.00
1
$1,519.00
MECH, HOURLY (D Yes (D No PLUMB, HOURLY Q Yes E) No I ELEC, HOURLY Q Yes Q No
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the prelininary information available and are only an estimate. Contact the Dept for addn7 into.
FEE ITEMS (Fee Resolution II -053 &. 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,420.00
F69s.f.
Remodel, Bath (<=300 sf)
1REA ESBAT
Suppl. PC Fee: E) Reg. () OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
s.f.
Remodel, Kitchen (<=300 sf)
REMRESKIT
Permit Fee:
$1,519.00
Suppl. Insp. Fee.S Reg.
Q OT
0.0
hrs
$0.00
Remodel, Other
REMRES2
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
�i454 cn�
G
Work Without Permit? Yes (F) No
$0.00
Advanced Planninp- Fee:
PLLONGRNGR
$104.12
Select a Non -Residential
Building or Structure
G
Strong Motion Fee:
IBSEISMICR
$20.00
Select an Administrative Item
�� Isis
Bldg Stds Commission Fee: IBCBSC
$8.00
SUBTOTALS:
$4,071.12
$5,372.00
TOTAL FEE:
4$"—*r
2
Revised: 1/19/2012