13030072CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21650 EDWARD WAY
CONTRACTOR: GREEN WORKS US
PERMIT NO: 13030072
OWNER'S NAME: RUTTENBERG GLORIA M
2500 OLD CROW CANYON RD
DATE ISSUED: 03/14/2013
OWNER'S PHONE: 4082525293
SAN RAMON, CA 94583
PHONE NO: (925) 272 -4590
JOB DESCRIPTION: RESIDENTIAL COMMERCIALE]
LICENSED CONTRACTOR'S DECLARATION
X33 9 2
REMODEL BATHROOM TO REPLACE (E) TUB WITH (N)
License Class Lic. #`.'
►C ` S _
WALK -IN BATHTUB, SAME LOCATION & ADD
DEDICATED
I hereby affirm that I am licensed under the provisions of Chapter 9
GFCI CIRCUIT.
(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: $5000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 35618010.00
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DA 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 CALLED INSPECTION.
AST
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
City in consequence of the
'
costs, and expenses which may accrue against said
ued Date:
granting of this permit. Additionally, the applicant under and will com
with all non -point source regulations per the Cup unicipal Code, Section
9.18.
&-3
RE- ROOFS:
Signature Date 3/14
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.
❑ E LDER DECLARATION
Signature of Applicant: Date:
I hereby a at I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
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 I
will maintain compliance with the Cupertino Municipal Code, Chapt and
performance of the work for which this permit is issued.
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:
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
CONSTR AGENCY
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
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 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
" V
CONSTRUCTION PERMIT APPLICATION !�„D
10 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION n
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
CUPERTINO (408) 777 -3228 • FAX ((408) 777 -3333 • buildiinng0gugertino.ora
NFW MNCTRT W..TION 171 AnnrrTnm I 1 Ar TFRATTnM /TT I 1 RFVTCTnXT /nPT:PQT?PTI nPTI-T11TAT PFATrtTT3t
PROJECT ADDRESS 5 O IJ
J V �
A 11 b J O `%•/ } r /
OWNER NAME / Ib,R1 cJ T TC/J C
o 2. 52 93
ILL
E-MAIL
STREET ADDRESS
7
CC�rA�
O /
FAX
r
?I C/ � _ S
CONTACT NAME
PHONE
E -MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER- BUR.DER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME GREENWORKS US
LICENSE NUMBER
668492
LICENSE TYPE
B,C33
BUS. LIC #
COMPANY NAME GREENWORKS US
E -MAIL
FAX 925- 265 -4590
STREET ADDRESS
4301 LAKESIDE DR.
CITY, STATE, ZIP
RICHMOND CA 94806
PHONE
925 - 272 -4590
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK REPLACE EXISTING TUB WITH NEW WALK -IN TUB - SAME LOCATION.
ADD DEDICATED GFCI CIRCUIT.
EXISTING USE
PROPOSED USE
CONSTR. TYPE
# STORIES
I
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODELAREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECKTORCH AREA GARAGE AREA: LIDETACH
I
❑ ATTACH
I
# DWELLING UNITS:
IS A SECOND UNIT ❑YES
SECOND STORY []YES
BEING ADDED? ❑NO
ADDITION? []NO
PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN YES
❑[]NO
�.'GE
TOTAL VALUATION:
PLANNINGAPPL# []NO PLANNING APPROVAL LETTER
EICHLERHOME?
$5,000.00
By my signature below, I certify to each ofthe following: I am the property owner or authorized agent to a6 t rty 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 with all applicable local
ordinances and state laws relating to building cons au onze pre pertino to enter the above - identified property for inspection purposes.
Signature of Applicant/Agent: Date: %
SUPPLEMENTAL INFO ION IRE D
PL,,,.aii!j„CHEGK TYPE , ,..
ROUTING SLIP
New SFD or Multifamily dwe pply for demolition permit for
_
existing building(s). Demolition permit is required prior to issuance of building
�R x>tE COUNTER
stln DBVC PLAN xEVtrw
permit for new building.
., ❑ EXPR'os
❑' PLANNING PLAN REVIEW
_ Commercial Bkigs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD >
El PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
p LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
El MAJOR •
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
BldgApp_2011.doc revised 06121111
1W�,�� CITY OF CUPERTINO
FF.F. F.CTIMATnR _ RITII,IIING DIVNION
Li,
ADDRESS: 21650 EDWARD WAY
QTY/FEE
DATE: 03/14/2013
REVIEWED BY: MELISSA.. -
Plan Check Fee:
APN: 356 18 010 .
BP #:
60 s.f.
$600.00
'VALUATION:
$5,000
%PERMIT TYPE: Building 'Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex
p
$0.00
PME Plan Check:
PENTAMATION 1 R3SFDREM
USE:
PERMIT TYPE:
WORK
REMODEL BATHROOM TO REPLACE E TUB WITH N WALK -IN BATHTUB SAME LOCATION &
SCOPE
ADD DEDICATED GFCI CIRCUIT.
$0.00
A,fecb. Plan Check
iLlech. Permit Fee:
Other ;llech. Insp.
R1ech. Imp. Fee.-
NOTE: This estimate does not incluo
Plumb, Plan Check Elec. Plan {:;heck
Plumb. Permit Fee: LTlec• Permit Fee:
Other Plumb Insp, Other E^,'lee. Insn, LJ
Plumb. h7sp. Fee: Elec. Insp. Fire:
due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate Contact the Dept /or aaan'l info.
FEE ITEMS (Fee Resolution 11 -053 E . 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
60 s.f.
$600.00
Remodel, Bath (< =300 sf)
LU1 2ESBAT
Suppl. PC Fee: (E) Reg. ® OT
0.0
fns
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee Reg. ®OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
rgaF
r:
A,fecb. Plan Check
iLlech. Permit Fee:
Other ;llech. Insp.
R1ech. Imp. Fee.-
NOTE: This estimate does not incluo
Plumb, Plan Check Elec. Plan {:;heck
Plumb. Permit Fee: LTlec• Permit Fee:
Other Plumb Insp, Other E^,'lee. Insn, LJ
Plumb. h7sp. Fee: Elec. Insp. Fire:
due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate Contact the Dept /or aaan'l info.
FEE ITEMS (Fee Resolution 11 -053 E . 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
60 s.f.
$600.00
Remodel, Bath (< =300 sf)
LU1 2ESBAT
Suppl. PC Fee: (E) Reg. ® OT
0.0
fns
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee Reg. ®OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
(.,onsiP- uctton :Tire:
A(Aninistrative .Fee:
®
Work Without Permit? ® Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
Travel Documentation Fees:
Strong Motion Fee: IBSEISMFCR
$0.50
Select an Administrative Item
Bldy, Stds Commission Fee: IBCBSC
$1.00
w.
$1.501
$600.00
�. ARM $601.50
Revised: 01/01/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014 -3255
Telephone: 408- 777 -3228
C U P E RT 1 N O Fax: 408 - 777 -3333
CONTRACTOR / SUBCONTRACTOR LIST„ 17 „
JOB ADDRESS:
€P f/j2
PERMIT # ( `
OWNER'S NAME: o
J r'- fZ
PHONE # 0 2 S Z- z
GENERAL CONTRACTOR:
BUSINESS LICENSE #.
.ADDRESS: 'A-30
E
CITY /ZIPCODE: -. ,1 ' O
*Our municipal code requires all businesses working in the city to have a City of Cupertmor>businesg license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE. SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE ON AXITY OF CUPERTINO
BUSINESS LICENSE. r
I am not using any subcontractors: /1-3
attire Date
Please check applicable subcontractors an ete the following information:
V
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
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SAFEGUARD TUBS
A DIVISION OF GREENWORKSUS
CSLB #668492
4301 Lakeside Drive. Richmond. CA 94806
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