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12090192CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10700 STOKES AVE I LINDA A1C`fOR: MILLS THEODORE 1 AND I PERMIT NO: 12090192 OWNER'SNAME: MILLSTHEODOREI AND LINDA M 110700 SPOKES AVE IDATE ISSUED: 09/212012 I OWNER'S PIIONF: 4082578484 1 CUPERTINO, CA 95014-1237 1 PHONE NO: ❑ LICENSED CON'I'RACI"OR'S DECLARATION License Class Lie. 0 Contactor hereby affirm that I am licensed under the 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 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 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 die work for which this Perron is issued. ,%PPI,ICA,N I' CERI"IFICA"1'ION 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 mrd 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 liahilities,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 regulatirns per the Cupertino Municipal Code, Section 9.18. Date ❑ OWNER -BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Lav for one Of the following two reasons: I, as owner of the property, or my cmployces 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 ofthe property, am exclusively contracting with licensed contactors to construct the project (Sec.7044, Business & Professions Code), 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 perfamtance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, l 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 ceniticate 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 he deemed revoked. APPLICANT CFRTI FICATION 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 die granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per,�ic Cupertino Municipal Code, Section 9.18. 19 7 X // Z.// I,/ i,1v 1,-7 BUILDING PERMIT INFO: BLDG r ELECT r. PLUMB I`I NIECH I- RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: BATHROOM REMODEL (40 SQFT) Sq. Ft floor Area: I Valuation: $2500 ANN Number: 32649012.00 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: ✓Fr4/y /4rd'�• Date: _"�/ •l�' 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 COVIiRINGS "1"0 BE CLASS "A" OR BETTER I IA"LARDOUS MATERIA S DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California llealth & Safety Code, Sections 25505, 25.533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the tiny Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the lealth & Safety Code. Sections 25505, 25533. and 25534. Z CONS 141)Cl'ION 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 ARCIII'fECI"S DECLARATION I understand my plans shall be used as.public records. Licensed CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • bulldinaOcuoertino.ora Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS 67?Qa 5` osz f)5 APN BP# OWNER NAME rw/ /L`5 OWNER ADDRESS m/L' DESCRIPTION OF WORK: y2 B- SCS !�'OlJ✓1'7 We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verity this information.) X1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. X 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. X3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. x 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. _4_5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. X6. 1 understand if I am considered an "employer" under state and federal law, I must register with the slate and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. _Z._7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. X8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for . any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OumerBuilderForm 2010.doc revised 04/14/10 —K-9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. X 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 'C 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. X 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building,permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's sf natu Property Owner's Signature: / Date: dP 1Z_ - -- -- --- --------------------------- -------- ---- ------- - ------ ---- - ------ ------------------ -- ----- ---- ------aw ---- ---- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderFOrm 2010.doc revised 04/14/10 CUPERTINO I I� I I MFW r`nNST'R 111 710N c., -2-09 o ( q -2-- CONSTRUCTION CONSTRUCTION PERMIT APPLICATION millsw COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 amp (408) 777-3228 • FAX (408) 777-3333 • buildingCcDcuoertino.org n ADDITH)N IN AITPRAT10N/TI F1 RFV1SI(­)N/r)FFFRRFD ORirH,JAl_PFRMITN PROJECT ADDRESS /O2 0 � �// 1-r C // /� ` APN 4 / I n ,� I /Y>L �/�(^V PHONE/ym ,Z6 7�/L/61( OWNER NAME 7/�OCDOOa& // E-MAIL���� 4. GO STREEI'ADDRESS SR�I� CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FA.X *wNTR ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGQKEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC4 COhIPANY NAME E-h1AIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS, LIC M �f • COMPANYNAME 5 // i E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK V�C6,e Stift vQ/tis , EXISTING USE PROPOSE USE CONSTR.T'PE I -STORIES )- USE TYPE OCC. SQ.FT. VALUATION (S) 1 C� EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA ✓g 103 YD BATHROOMU KITCHEN OTHER R IODELAREA r6? REh10DELAREA / REMODEL AREA / PORCH AREA DECK AREA TOTAL DECKIPORCH AREAI GARAGE AREA: DETACH ' ❑ATTACH X DWELLING UNTrS: IS A SECOND UNIT ❑lTs SECOFDS`rORY ❑YE$ BEING ADDED! ONO ADDITION! NO PRE -APPLICATION ❑YFS IF YES, PROVIDE COPY OF NO PLANNING APPROVAL LETTER PLANNGAPPLM [:]NOAN NI[:]NO IS THE IILDC,W ❑YES EICHLER DOME? ❑NO FRECE1VED, BY T"1 r ', y. � ; 5\ *�kP[ � �jtyl� TOTAL VALUATION: By my signature below, 1 certify to each of the following: I am the property owner or authorized agent to act on the propeny owner's behalf. 1 have read this application and the information 1 have provided is torr et. 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 b di const ion. I aut ize re s o(C pertino to enter the above -idennttified property for inspection purposes. Signature of Applicant/Agent: Date: A ✓if 12— LSUPPLEMENTAL SUPPLEMENTALINFORMATION REQUIRED,y?f:L�ciiE�c��'`'T)ie,�`�i:1`�r`P'-Rou'�i SFD or Multifamily dwellings: Applyfor demolition pcm)it for aC'o >r vtiip '- 'SUIL's.Di IL\aC dP:.PrAr\ RatE\rIEwNeo existing building(s). Demolition perTnit is required prior to issuance of building A` permit for new building.❑J EXPRi ss '�'3y, r+iLat "2 �f;:€q-r.< PLANNING PITA\ RESTESaN s' r Commercial Bldgs i rovide a completed I lazardous Materials Disclosure form Hazardous Materials being this _ if r 1❑,( sr tnua RD - -f > (��,,r❑` �r Li- >..Lp,?r+L,,.s� I Un1ICw ORK s xf titi`a* J any are used as pan of project. n.�i1 LAHOFyS H"='t .. Ah© FIRE DEP r' i„-, hr' crP�4 _ Copy of Planning Approval Letter or Meeting with Planning prior to Building Permit ,. 1 D-^a,*.;N-L's'^`i ❑ tl\JOR TT ,�- q' ❑ SSNr\R)SStw FR DISTRICT submittal of application.�tti iENAIRONMENTAL HEALTH�.(..�:1t BldgApp_20/ 1. doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION L.MFADDRFSS: 10700 Stokes Ave Plomb. Plan Check DATE: 09/21/2012 REVIEWED BY: Sean Plumb. Permit Fee: APN: BP#: I 'VALUATION: $2,500 *PERMIT TYPE: Building Permit Plumb. Insp. Fee: PLAN CHECK TYPE: Alteration / Repair PRIMARI' USE: SFDorDuplex $0.00 PENTAMATION PERMIT TYPE: 1R3SFDRE WORK Bathroom remodel 40 sq ft). $0.00 SCOPE NOTE: This estimate sloes not include fees slue to other Departments (i.e. Planning, Public H'orks, Fire, Sanitary Server District, School District. etc ). These fees are based on the nreliminan, information available and are onh, an estinntte. Contact the Dept for adda7 into. FEE ITEMS (Fee Resolution 11-053 E1X 7/1/I1) Alech. Plan Cheek Plomb. Plan Check Flee. Plan Check Mech. Permil Fee: Plumb. Permit Fee: F.lec. Permit Fee: Other A/ech. Insp. Oilier Plumb lnsp. Other Elec. Insp. Aledi, Imp. Fee: Plumb. Insp. Fee: Flee. Insp. Fee: NOTE: This estimate sloes not include fees slue to other Departments (i.e. Planning, Public H'orks, Fire, Sanitary Server District, School District. etc ). These fees are based on the nreliminan, information available and are onh, an estinntte. Contact the Dept for adda7 into. FEE ITEMS (Fee Resolution 11-053 E1X 7/1/I1) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 40 s.f. $600.00 Remodel, Bath (<=300 so IRFA9RESBAT Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee0 Reg. Q OT0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consuvlction Tux: Adminisnrnive Fee: Work Without Permit? O Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure (F) 0 i Travel Docmnentnlion Fees: Strone Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item 131dg Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $600.00 TOTAL FEE: F $601.50 Revised: 07101/2012 � #: / 7/ rl ƒ ƒ \/\� < 0 & isƒ \. oo0 \ §}k ( /&#13=2 f' (D SU P /k\ 3 a mƒ 2 2!J£ «CL)$\c }}»ƒ/\ gar, 391. -,q!�§R ƒ} � SCOPE OF WORK: Project shall comply with the 2010 California Building (Base code 2009 IBC), 2010 Residential (2009 IRC), Plumbing (2009 UPC), Mechanical (2009 UMC), Electrical (2008 NEC), Fire (2009 IFC) and Energy Codes (2008 Building Energy Efficiency Standards) Energy code mandatory lighting measures: 1. All permanently installed high efficacy luminaires shall be switched separately from low efficacy luminaires. (150(k)(7)) 2. Permanently installed luminaires in bathrooms, garages, laundry rooms and utility rooms shall be high efficacy luminaires OR are controlled by an occupant sensor(s) certified to comply with Section 119 that does not turn on automatically or have an always on option. (150(k)(10)) Plumbing plan notes: 3. Water closets shall have an average water consumption of not more than 1.28 gallons per flush. (CPC 402.2) 4. Shower heads shall have a water flow not to exceed 2.5 gallons per minute. (CPC 402.1.1) 5. Faucets in kitchens, wet bars, lavatories, laundry sinks, etc shall have a water flow not to exceed 2.2 gallons per minute. (CPC 402.1.2) 6. Shower stalls shall have a clear interior finish area of 7.1 sq. ft. and be able to accommodate a minimum 30 inch circle at the threshold level. These clearances shall be maintained up to a height of 70 inches above shower drain. (CPC 411.7) 7. Shower compartments and walls above bathtubs with installed shower heads shall be finished with a smooth, nonabsorbent surface to a height not less than 72 inches (6 ft). (CRC R307.2) 8. The maximum hot water temperature discharging from the bathtub, shower and whirlpool bathtub filler shall be limited to 120 degrees Fahrenheit. The water heater thermostat shall not be considered a control for meeting this provision. (CPC 414.5 & 418.0) 9. A 30 -inch clear width for water closet compartment and 24 inch clearance in front of water closet. (CPC 407.5) Electrical Plan Notes: 10. The installation of smoke alarms in all of the following areas shall be provided: (R314.3) a. On the ceiling or wall outside of each separate sleeping area in the immediate vicinity of bedrooms. b. In each roam used for sleeping purposes. 11. The installation of carbon monoxide alarms in the following areas shall be provided: (R315.1) a. Approved carbon monoxide alarms shall be installed outside of each separate sleeping area in the immediate vicinity of the bedrooms and on every level including basements in dwelling units that have fuel -fired appliances or attached garages. 12. At least one 20 amp branch circuit shall be provided to supply bathroom receptacle outlets. Such circuits shall have no other outlets. (CEC 210.11(C)(3)) 13. All receptacles in bathrooms, garages, accessory buildings, outdoors, crawl spaces, unfinished basements, kitchens (where receptacles serve counter top surfaces), laundry, utility, wet bar sinks (within 6 feet of the edge of the sink), shall have ground -fault circuit interrupter (GFCI) protection. (CEC 210.8) 14. In all areas specified in 210.52, all 125 -volt, 15- and 20- ampere receptacles shall be listed tamper-resistant receptacles. (CEC 406.11) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10700 STOKES AVE CONTRACTOR: MILLS THEODORE 1 AND PERMIT NO: 12090192 LINDA M OWNER'S NADIE: MILLS THEODORE 1 AND LINDA M 10700 STOKES AVE DA'Z'E ISSUED: 092112012 OWNER'S PHONE: 4082578484 CUPERTINO, CA 95014-1237 PHONE NO: ❑ LICENSED CONTRACI'OR'S DECLARATION .JOB DESCRIPTION: RESIDEN`FIALU COMMFRCLSL❑ License Class Lic.4 BATHROOM REMODEL (40 SQFT) 9/27/12 REVISION #I -MAKE MINOR MODIFICATIONS TO Contractor Date REMOVE AND REPLACE 3 LIGHTSjAN\�--LIGHT TO I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business S Professions UTILITY ROOM Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: I have mid 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: $2500 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 APN Number: 32649012.00 Occupant) Type: permit is issued. APPIACANTCERTI FIC TION I 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 mid smote Imes relating N+[THIN 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 accrue against said City in consequence of the p " )��� �T`j / - 9,7 -/� granting of this permit. Additionally, the applicant understands and will comply Issued by: ,,,../// Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Rb: 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. ❑ OWNFR-BUILDER DECLARA'T'ION Signature of Applicant: Date: 1 hereby affirm that 1 am exempt from the Contractor's License haw fortune of the following two reasons: AL1, ROOF CONTRINGS'TO 13E CLASS "A" OR RE'I'FER 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) 1, as owner of the property, am exclusively contracting with licensed contractors to IIA%ARDOUS MATERIA[ S DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I hate read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & Safety Code, Sections 25505.25533, and 25534. I will hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Ilealth & Safety Code, Section 25532(x) 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 flay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino lunicipal Cole, hapten 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Section 505 _ 3J. J Section 3700 of the Labor Code, for the performance of the work for which this Owner or authoriz Jpgeor ate: 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 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. w'ork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPI,ICAN'I'CER'I'IFIC,\TION 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 mid 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, ARCUI'TF,CI"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 pernit. Additionally, the applicant understands and will comply with all non-point,source regulati as per tl Cupertino Municipal Code, Section Licensed Professional 9.18. r `� p �7— JL Signa re ate 12 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING� ` wY�7l�ld 1L 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 1tl 'It (408) 777-3228 • FAX (408) 777-3333 • buildingCcDcuoertino.oro I-INEW CONSTRUCTION ❑ ADDITION 1JALTERATION/TI ❑ REVISION/ DEFERRED ORIGINALPERNIITN �C/4/G1/� PROJECT ADDItF55/O 7670 C; O d x__ APNB OWRNERNAME PHONE ZS7� �/ �J E -MAI/ �/ Z // V�\ -5 O� �'u r IC 044 STREET ADDRESS 5 �AUV r'✓�1yp� CITY, STATE, ZIP FAX CONTACT NAME ,/ PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX )9(10AWER ❑ OWNER -BUILDER, ❑ OWNER AGFI.T ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME C. ! /T' LICENSE NUMBER LICENSE TYPE BUS. LIC a COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE. ZIP PHONE ARCHITECTlENGINEER NAME LICENSE NUMBER BUS. LIC d COMPANY NAME E-MAIL FAX STREET CITY, STATE, ZIP PHONE /pADDRESS � / An, EXISTING USE PROPOSED U . CONSTR.TYPE N STORIES J USE TYPE OCG SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA FORCH AREA DECK AREA TOTAL DECK/ORCH AREA GARAGE AREA: DETACH []ATTACH I DWELLING UNTrS: IS A SECOND UNIT ❑YES SECOND57ORY ❑YES BEINGADDED? ❑NO ADDITION'? NO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THC DLDG A-YES ARECEIVED,B a.HV�7 5' 7 TOTAL VALUATION: NO PLANNING APPROVAL LEITER PLANNINGAPPLN ❑ AN EICHLER HOME? ONO By my signature below, 1 certify to each of the following: I am the property owner or authorized agent to act on the property ow'ner's behalf. I have read this application and the information I have provided IS co L I have read the Descrip ion of Work and verify it is accurate. I agree to comply With all applicable local ordinances and state laws relating to rdi -coil Ion. taut rite r�Res Lives of Cupenino to enter the above -identified property for inspection purposes. Signature of ApplicanUAgent: Date: SUPPL: - :NTAI. INFORNIAT10 SQUIRED r,F._ � � ��.�'�- +aSROUT I\C 51'II'.(N'z;.. cw;_; • New SI'D or Multifamily dwellings: Apply for demolition pcmliL for Demolition is issuance t O\ER'TIIE COU\TERIaj SM pRUII DI\G91.A\HF\IF\\T,� existing building(s). permit required prior to of building r -e u\\ permit for new building. p�'tIRsss''r>i yrq}°F fy`;il I�c'ru\ktvlewj 74 _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure r❑CsrA\I A) RIAA kL; r4ilf J 1 O,runLlc S� R Y a 1�,�"'}6 form if any I lazardous Materials arc being used as part of this project. ` t, 1" sil � �" ❑wId RCF'. f�\ $ - f�et.... Copy of Planning Approval Letter or Meeting with Planning prior to G.fie. .f lv L; s _ Submittal of BuildingPermits application. IA .1`ors jy y�Y y ❑`S \NIIAk1.5F\\ER UISI RICIN +�^ �'r,a, PP ����''````3+�5,�TM,yF' '-��,F � 3.7 rp e y❑ e°,� �,r'J .,, - A ��hJ1..�._ ...i_.l O�It E\\ IkONNI ENT,wL IIEA LTIIEi�'1 �.� BldgApp_20/1.doc revised 06/21/11 ����� ���� CITY OF CUPERTINO I►Y.///.I FEE ESTIMATOR — BUILDING DIVISION JAFADDRESS: 10700 Stokes Ave DATE: 09/2712012 REVIEWED BY: Sean Alech. Permit Fee: APN: BP#: 'VALUATION: $300 *PERMIT TYPE: Building Permit PLAN CIIF.CK TYPE: Alteration / Repair PRIMARY SFD Or Duplex USE: Elce. Insp. /--cc: PENTAMATION 1 REAP11 PERMIT TYPE: WORK Revision #1: Make minor modifications to existing bathroom remodel; remove and replace 3 lights SCOPE and add (1) light to utility room. NOTE: This evtinrate does not include fees clue to otter Departments (i.e. Planning, Public li'arks, Fire, Sanitary Sewer District, School District. etc.). These fees are hased on the nreliminan, information available and are onh, an estinmte. Contact the Dept for addtt7 info. FEE ITEMS (Fee Resolution 11-053 E/f 7/1/11) Nech. Plan Check Phoob. Plan Check Elec. Plan Check 1 0.0 1 hrs $0.00 Alech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERAI/T Other Afech. Insp. Other Plumb lase. ED Other Elec. Insp. 0.0 1 hrs $45.00 Hoch. Itsp. Fee: Plumb. Insp. Fee: Elce. Insp. /--cc: NOTE: This evtinrate does not include fees clue to otter Departments (i.e. Planning, Public li'arks, Fire, Sanitary Sewer District, School District. etc.). These fees are hased on the nreliminan, information available and are onh, an estinmte. Contact the Dept for addtt7 info. FEE ITEMS (Fee Resolution 11-053 E/f 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # $67.00/BREAIFLIT Electrical Fixtures, Lighting Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. FeeQ Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 Cousn-tiction Tar: Administrative Fee: IADMIV $42.00 Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure O A Travel Documentation Fee: 1TR,IVDOC $45.00 Strong Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item Bldg Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: $133.50 $67.00 TOTAL FEE F $200.50 Revised: 07/01/2012 II w 0 F/5 ai cr � LLM �i§m {)5\ \�\ 2 !o ±;&« k} Co } \>§ �}\ $ .2 0 2 cL k�E k)�0 I|\ §»! »;�ajE 2] E a� „ -_# & \_\E(� �s>\ 0 o CL\'rh $a /i°) &k2 �i§m J O= Z E itm CL Wo 0- CD 0 `— U► co m N A N CL W cn E W; �� LU > m W 3 a) ro co 3 =u co Z N (n c6 .0 �� �IIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIII J O Co CD O E O m`JX O O U� W O U 0 �i C O U N a) ro co 3 =u co Z N (n c6 .0 �� �IIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIII Co CD O coU CO LL a2S Ln V) = — N U J — \U 0 — (b IIIIIIIIIIIIIIIIIIIIIIIIIilllllllllllllllllllllllll' ' T cu 3: v O O N m IIIIIIIilllllllllllllllllllllllllllillllllillII U T V