12120025 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21357 METEOR DR. CONTRACTORr�BE PERMIT NO: 12120025
ED
OWNER'S NAME: BOLSTER CHARLES L AND H R U rK-S U S DATE ISSUED:12/06/2012
OWNER'S PHONE: 4087460851 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class3 e33 C S7 Lie.# GG � 1417 2— REPLACE EXISTING TUBE W/NEW WALK IN TUB,ADD
Contractor GR E'F W f
/� ' I1 V-K 5 Date DEDICATED GFCI CIRCUIT FOR TUB
�Z Z
I 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 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:$10000
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 Number:32643006.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 and state laws relating WITHIN 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 DAY + M 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
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.
/ RE-ROOFS:
Signature Date / Z 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.
❑ NE ILDER DECLARATION
Signature of Applicant: Date:
1 hereby a at I em exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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 contactors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I 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: Health&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 1
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 Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:)Z�L
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,1 CONS ION 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
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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
GENERAL PERMIT APPLICATION n' M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION v
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 M I C V
CUPERTINO (408)777-3228•FAX(408)777-3333•buildina(a),cuoertino.ora \$
PLUMBING MECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 7-1367
.Mr g-Op, m APNp 43 OO' ^
OWNER NAME I�o5C 81013745 /` P ONE .^q6-M ! EMAIL lJ�
STREET ADDRESS Z 3 il4r7r0� x CITY.STATE, - / - 7 FAX
CONTACT NAME (S^�L ��/'�l� C-0 PM-7
�f� / -Z�-T.`'�^O E-MAIL
STREET ADDRESS it [' '`y'LL OI.D(,�"1' /' CITY,STATE,IP, OA) `7t�,A . ? 1 FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME &1'FA) IJCVv -1� LICENSE NUMBER 66(? q?z LICENSETYPE BUS.LICA
COMPANYNAME / � CA) Y v EMAIL %O`6 FAX
STREETADDRESS (� CI STATE ZIP PHONE
Z on dig utoJJ C-A-A) G.nl I ,r ✓ ,14--fOAI `��5� 9`Z,5 . 27 4S90
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC p
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE MEDUPLEX
BUILDING: DCIAL MULTI-FAMR.Y PR0fl=INWILDLAND ❑ YES PROIECIN ❑YES ISTHEBLDGAN ❑ YES
❑
URBAN INTERFACE AREA ❑ NO FLOODZONE ❑NO EICHLER HOME' ❑NO
DESCRIPTION OF WORK ', - -
(CI cJ n- l.J
t-A 157 1 r, 1Clr A+_rfc9A)
n71 c.9-7L a (Sr-Cl G l fL-cuJ( - 7 TL)
TOTAL VALUATION: ) 2
VVV RECEIVED BY,
By my signature below,l certify to each of the following: I ann 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 withal]applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cu rt enter the above-identified property,for inspection purposes.
Signature of Applicant/Agent: Date: 1-7-16 Z—
c-SUPPLEMENT TION REQUMED QMCE;USE.ONLY
❑ OVER-THECOUNTER
W ❑ EXPREss
m ❑ STANDARD
❑ LARGE
ry
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/ll
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21357 meteor dr DATE: 12/0612012 REVIEWED BY: mendez
APN: BP#: 'VALUATION: $10,000
*PERMIT TYPE: Building Permit I PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD Or Duplex 2nd Unit? Yes No PENTAMATION 1 R3SFDREM
USE: OTC. 0Yes (F)No I PERMIT TYPE:
WORK
SCOPE
OCCUPANCY TYPE: TYPE OF FLRAREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
R-3 (Custom) II-B,III-B,IV,V-B 0 $0.00 $0.00
TOTALS: F 0 $0.00 $0.00Nis
MECIT,HOURI 7l' O;Yes,;�e No ELEC,HOURLY .,Q Yes'^ QW o
,bfech. Plan Check Plumb.Plan Check 0.0 Ins $0.00 Elec.Plan Check 0.0 1 Ins $0.00
,bfech. Penni[Fee: Plumb.Permit Fee: IPPERMIT Elec.Permit Fee: IEPERMT
Oder nfech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elea Insp. 0.0 hrs $45.00
,leech. Insp. Fee. Plumb. Lisp. Fee: I Elee.Insp. Piet:
NOTE:This estimate does not include fees due to other Departments(Le Planning,Public Works,Fire,Sanitary Sewer District,School
District etc . These fees are based on the prelimina in ormadon available and are only an estimate. Contact the De t tor addn'l in to.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/121 FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 F-1-1 # Electrical
Suppl. PC Fee: Q Reg. Q OT 0.0hrs $0.00 $45.00 1BREMRECEP I Recep/Switch/Outlets
PME Plan Check: $0.00 1 # Plumbing
Permit Fee: $0.00 $10.00 1BPFIXTURE Fixture or Trap
Suppl. Insp. Feer Reg. Q OT0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $90.00
Construction Tux:
Administrative Fee:
Work Without Permit? 0 Yes O No $0.00 E)
Advanced Planning Fee: $0,00 Select a Non-Residential O
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure
i
Strong Motion Fee: IBSEISMICR $1.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00 l5 '
,� $137.00 $55.00 TOTAL FEE:` $192.00
s 5 .a .xff.Yl .iU�kti7gli ' 1 :�:
Revised: 10/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
cqG��&A 0��I
CUPERTINo
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS:Z 5 6 PERMIT#
OWNER'S NAME: E0 --9 PHONE# 401 - 74f w Ord
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS:2-660 DL ?,=J c-,+ D CITY/ZIPCODE: /En/ lZA-M0n1 9� 3
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: 6 /� Z
gnature Date
Please check applicable subcontrcomplete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date