12090110 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21825 HYANNISPORT DR CONN RACI'OR:BAY AREA PERMIT NO: 12090110
CUSTOM BUILDERS INC
OW'NER'S NAaus: ED OR JULIE IRVIN 1002 S DE ANZA BLVD STE AI DATr Issum):09/12/2012
OWNER'S PHONE: 4084465676 SAN JOSE,CA 95129 PHONE NO:(408)446-1200
❑ LICENSED CONfRACI'OR'S DECLARATION r' r r
HUII,DING PERMIT INFO: BI,DG ELECT PLUMB
License Class Lic.H ❑ r
M FIC II RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that 1 am licensed under the prueisiuns of Chapter 9 .IOBDESCRIP11ON: REMODEL45SQI71'OBATHROOM
(commencing with Section 7000)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 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. Sq.Ft Floor Area: Valuation:55000
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 APN N umber,35613045.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have feud 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 Imes relating WITHIN l80 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 Cupenino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicmm understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOF'S:
Signature Date All roofs shall be inspected prior to any roaring material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
1-1O\1'e ER-I3l1ILDFR DECLARATION
hereby affirm that 1 am exempt from the Contractor's License haw for one of Signature of Appl icant: Date:
the following two reasons: ALI,ROOF COVERINGS TO BE CLASS"A"OR BETH"R
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of pmpeny,am exclusively contracting with licensed contractors to HA7,ARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business R Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&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: IIcallh&Safely Code,Section 25532(a)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-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 contaminants as defined by the Bay Arca Air Quality Management District I
performance 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 provided for by the Ilcalth&Safely Code,Sections 25505,255334 and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
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 CONSrRUCIION 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 CERTIFICATION Lender's Address
I certify that 1 have read this application and slate that the above information is
correct.I agree to comply with all city and county ordinances and state Imes 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 ARG II'fECI"S ITh;CL,\R,\'PION
indemnify and keep harmless the City of Cupenino against liabilitics,judgments,
costs,and expenses which may aceme 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 conhply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
:M
IA
DDRESS: 21825 hyannisport dr. DATE: 09712/2012 REVIEWED BY: bob s.
PN: BP#: 'VALUATION: 55,000
'PERI\IITTI'PE: Building Permit PIAN CIIECK-I-\'PE: Alteration / Repair
PRI\I:C RI': - PENTAAL\PION
'USE:. SFD or Duplex PFRbII'I'Tl'PE: iR3SFOREM
-\VORK sfd bathroom remodel.
SCOPE
Alech. flan Check Ph un b. Plua Chord- Elec.Plan Chock
Neeh.Persil Fee: Plumb. Permit Fre: Fake.Permit Fee:
Orher.ilcrh. Insµ Other Plumb lnsp. Other F.lcr. Insp.
Aitch./rnP.Rs: Plumb. br;p. Fre: F.Ice.Insp. Fee:
NO TF. This ertintate does not includeJees due to other Departments(i.c. Planning,.Public Works. Fire,Sanitary Sewer District,School
District.etc.). These eas are based on the preliminan,information mailable and are onlp.un evtirnate. Contact the De t or addn'I info.
FEE ITEMS (b`ee Resolution 11-051 /:1/: 711111) FEE QTY/FEF, MISC ITEMS
Plan Check Fee: $0.00 45 s.f. Remodel, Bath (<=300 so
Suppl. PC Fee: Q Reg. O OT FO.0 hrs $0.00 S600.00 IR£AfRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feel@ Reg. O OT 0,0 11 s 50.00
PME Unit Fee: $0.00
PME Permit fee: $0.00
Consnvction Tax.
Adininistrettive Fce: O
Work Without Permit? O Yes 0 No $0.00 O
Advanced Planning Fee $0.00 Select a Non-Residential 0
Trm¢a Dorvtnenrarion Feesr Building or Structure 0
Id
Strong Motion Fee: 1BSEISAUCR S0.50 Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC I $1.00
SUBTOTALS: 1 $1.501 $600.00 TOTAL FEE: $601.50
Revised: 07/0112012
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION l
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 �C �1\
(408) 777-3228 • FAX (408) 777-3333• buildingng cuperlino.arq `�1
CUPERTINO
❑ NEW CONSTRUCTION ❑ ADDITION TALTERATION/l'1 ❑ REVISION I DEFERRED ORIGINAL PERMIT
PROJECT A?yI, _ APNtl
xp
OWNERNAME `n^ PlfEMAIL
STREETADDR�SS / CITY. STATEZIP FAX
Y G
CO,YrACT NAME P110. E E-NTAIL
STREET ADDRESS /) CITY.STATI' 7.Ir FAN
�I °I 1 -� r <S-1 z5
❑OwNER 0 owNER•IIUILDER ❑ OWNER AGENT ❑ CONTRACTOR DCONTRACTORAGE`rT O ARCHITECT ❑ENGINEER D DEVELOPER ❑ TENANT
CONTRACTOR NAME. LICENSE NUMBER LICENSETYPE BUS.LICE
L a
CONIPASYNAME ` 1 C ✓� E-MAIL FAN
VY
STRIE ADDRESS CITY.STATE ZIP P ONE
1 e 3 G 2co
ARCNITECTIENGINEER NAME LICENSE NUMBER BUS.LIC N
COMPANY NAME EMAIL FAN
STREET ADDRESS CRY,STATE ZIP PHONE.
DESCRIPTION OF WORK /
1 G 6 \'U p✓r+ Z C�iC / �U� G CJ(/
c /
FagTINGUSL' PROPOSE.0 USE CONSIA.tYPE •StORIES
USE TYPE OCC. SOFT. VALUATIONS)
E\ISTG NEW FLOOR DE\IO TOTAL
A AREA AREA NAREA
ATIROOET M KOCuLN OTHER
MODEL AREA REMODEL AREA REMODEL AREA
PORCHAREA DEN ARG TOTAL OECKMMORCH AR'\ GARAGE AREA: DETACII
DATTACH
I DWELLING ONUS: IS A srcusi,l lNrr ❑YES S!CO%DSTORY ❑YES
WANG AIMEDT DNo AIurTIOsv DNo
PRE-APPLICATION DYES If VIS,P0.OVIDE COPY OF 15TIMIII.11CdN 0YES RECEIVED BY: TOTAL VALUATION:
PLANNINGAPPLt ONO PLA,NNINGAPPROVEIt:IILI:RMIMI:• ONO
By my signature below,I cenify to each of the fat
I am the pLo itv o\vner or amborized agent to act on he propeny o\vner's behalf, I have read this
application and ar mromintum I have pmvie• Cr '-T truer reA le Description of%Vork and verify it is aeeumte. 1 agree to comply with all applicable local
ordinances and slam laws relating to I ding consuuelion. I! ori'r.e representatives of Cupertino to enter the above-identified propeny for inspection'purposes.
Signature ofApplie:indAgent: Date — ( _
SUPPLEh•IENTAI.INFORMATION ItGQUIRL'D PG%Ncn eel:TYPE, uotiri.Nr.sett'
Ne\v SP1)Dr\luhifmniH d\Yd lings: Apply for demolition permit for
'ue.eou,NreR Lz}- wi:nl a rl,s.Rt:Yu:w
existing building(s). Demolition permit is required prior to issuance of building
permit for nnv building. ❑ I:NI•RISS .❑ PL%SMSr PL\SRF.VIKw
_Commercial Bldgs: Provide n completed I lazardous,i laterials Disclosure ❑ SL\NIIARD' ❑ Penile w.liels
fortm if any Hazardous Materials arc heing used as pan of this project.
❑ L\Hf.l: ❑ a'1RE OErr. _
_Copy of I'lunning Approval Letter or(Meeting with Planning prior to -
submittal of Building Permit application. ❑ >IAION .U S.\�ITd R1'SI:\YEM mST'0.1C1"
• ❑ ;EN\'IRnF,U E?TA�III;.\(:I'll -
BIe18,4PV_2011.doe revised 06121/11