11080053 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10631 MERRIMAN RD CONTRACTOR:WAHID MOIED AND PERMIT NO: 11080053
MOIED SARA
ONVN 'R'S NAME:
CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# s
MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD NEW CLOSET SPACE FOR MASTER SUITE AND
(commencing with Section 7000)of Division 3 of the Business&Professions BEDROOM
Code and that my license is in full force and effect. (194SQFT)NEW WATER HEATER ENCLOSURE,REMODEL
BAT FI(120SQFT)&HALLWAY(80SQFT)
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. Sq.Ft Floor Area: Valuation:$4000
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is APN Number:34216083.00 Occupancy Type:
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 Issye�l Date:
Er OWNER-BUILDER DECLARATION
1 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
I,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
will 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).
I hereby affirm under penalty of perjury one of the following three I ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations: /r P1--
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
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this
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 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,1 Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,1 must
Owne uthorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Dater Cl 1 Q j
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 vmork'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
it nify and keep harmless the City of Cupertino against liabilities,judgments,
mnd expenses which may accrue against said City in consequence of the Lender's Address
p-aing of this permit.Additionally,the applicant understands and will comply
with all non-point source,{egulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.I R. /Jf
1 understand my plans shall be used,s public records.
Signature / Date v�c q ' G 2-011
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
10631 merriman rd.
DATE: 08/08/2011
REVIEWED BY: bobs.
JUADDRESS:
N
APN:
BP#:
"VALUATION: 1$4,000
"PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY
USE: SFD or Duplex
2nd Unit? ' Yes G No
OTC? 0 Yes E No
PENTAMATION
PERMIT TYPE1 R3SFDADD
:
WORK
addition new closets ace for master suite and bedroom new water heater enclosure remodel bath
�sfd
SCOPE
and hallway.
OCCUPANCY TYPE:
TYPE OF
CONSTPL
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-B,IV,V-B
194
$994.00
IADDPLCK
$963.00
IADDINSP
TOTALS:
194
$994.00
11
1 $963.00
AUI L these tees are based on the preliminary information available and are onlV an estimate. Contact the Dept for addh 11 info.
FEE ITEMS (Fee Resolution 11-053I
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$994.00
120 s.f. Remodel, Bath (<=300 sf)
$588.00 IREMRESBAT
Suppl. PC Fee: G Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
80 s.f. Remodel, Other
$392.00 IREMRESOTH
Permit Fee:
$963.00
Suppl. Insp. Fee:E) Reg. 0 OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Acoustical Fee:
0 Yes E) No
$0.00
Q
Work Without Permit?
0 Yes E) No
$0.00
0
'larnn' Fee;,
PLLONGRNGR
$25.22
Select a Non -Residential Q
Building or Structure 0
titron2 Motion Fee:
IBSEISMICR
$0.50
Select an Administrative Item
Bldg, Stds Commission Fee:
IBCBSC
$1.00
SUBTOTALS:
$1,983.72
$980.00
TOTAL FEE:
$2,963.72
Revised: 07/04/2011