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11080112 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1108 NOVEMBER DR CONTRACTOR:BETTER BUILDING PERMIT NO: 11080112 REPAIRS OWNER'S NAME: JILL&KEVIN PLOUSE 11318 CHAMPAGNE PL DATE ISSUED:08/15/2011 'NER'S PHONE: 4085645107 DUBLIN,CA 94568 PHONE NO:(925)479-9500 ❑ LICENSED CONTRACTOR'S DECLARATION r— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class/417/ Lic.# of3&0c) (� MECH RESIDENTIAL COMMERCIAL Contractor e S` o I( JOB DESCRIPTION: BATHROOM REMODEL AREA 72 SQ FT 1 hereby affirm that 1 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:$6000 I have and will maintain Worker's Compensation Insurance,as provi ed for by Section 3700 of the Labor Code,for the performance of the work or whi this APN Number:36217057.1108 Occupancy Type: permit is issued. `3 APPLICANT CERTIFICATION 1 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 DAYS FROM LAST CALLED INSPECTI N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,a e enses which may accrue against said City in consequence of the (_�4 grantin of thi permit. Additionally,the applicant understands and will comply Issued by: Date: l with all on-poi t source regulations per the Cupertino Municipal Code,Section 9.18. RE-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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that 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 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) 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. 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: 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 wit the 'upertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Seetiony 25505,25533,. nd 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:��O—gWit/ permit is issued. I 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 CONS'T'RUCTION 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 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 ,mnify and keep harmless the City of Cupertino against liabilities,judgments, s,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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408 77-3333 • buildingCcDcupertino.org l (Ox <2 ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESSJf1 c /,L, oL it i i ,r.-f1 I� APN# OWNER NAME PHO r � STREETADDRESS - �Ll CifA// C7V��A CITY,,S3ATE. ��'^V e jam, FAX CONTACT NAME / PHO E-MAII_ 12 STREET ADDRESS *l �/ STATE, ZIP �' F ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMEJ I l -��L LICENSE BFB$ LICEN BUS.LIC# i/ l /� � � COMP NAME2 !C r L ie,&ko k&MAIL STREET S PHONIC ) , jT ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE _'ESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA 1 [2-7 BATHROOM KITCHEN OTHER V REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DOCK AREA TOTAL DECK/PORCH AREA GARAGE AREA LIDETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ONO ADDITION? ONO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY:. TOTA�VALUATIONL� PLANNING APPL# ONO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below,I certp to each the following: I am the property owner or authorized agent to act on the prrperty owner's behalf. I have read this application and the information I have pro ide-moi o escription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relate g t ng construction. I authorize repre ntatives of Cupertino to enter the above-identified property for inspection purposes. Signature ofApplicanbid Agent: \ Date: TC id d t, SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ZOUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for LI OVER-THE-COUNTER BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . . 36217057 . 1108 DATE ISSUED. . . . . . . : 08/15/2011 RECEIPT # . . . . . . . . . BS000014435 REFERENCE ID # . . . : 11080112 SITE ADDRESS . . . . . : 1108 NOVEMBER DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : JILL & KEVIN PLOUSE ADDRESS . . . . . . . . . . : 1108 NOVEMBER DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PATRICK WHARTON CONTRACTOR . . . . . . . : PATRICK WHARTON LIC # 29856 COMPANY . . . . . . . . . . : BETTER BUILDING REPAIRS ADDRESS . . . . . . . . . . : 11318 CHAMPAGNE PL CITY/STATE/ZIP . . . : DUBLIN, CA 94568 TELEPHONE . . . . . . . . : (925) 479-9500 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 6, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 6, 000 . 00 0 . 60 0 . 00 0 . 60 0 . 00 1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 00 0 . 00 1REMRESBAT SQ FEET 1 . 00 588 . 00 0 . 00 588 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 704 . 60 0 . 00 704 . 60 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 704 . 60 MC --------------- TOTAL RECEIPT 704 . 60 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 1108 november dr. DATE: 08/15/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$6,000 Y PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM USE: p PERMIT TYPE: WORK bathroom remodel non structural SCOPE NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept-for addn'1 in o. FEE ITEMS (Fee.Resolution 11-053 I ff. 7/1,"]11 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.f. Remodel,Bath(<=300 sf) Suppl.PC Fee: Reg. OT 0.0 hrs $0.00 $588.00 IREMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-E) Reg. C) OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes (E) No $0.00 0 Work Without Permit? 0 Yes E) No $0.00 Planning Fee: $0.00 Select a Non-Residential E) Building or Structure 0 Strom Motion Fee: IBSEISMICR $0.60 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.60 $588.00 TOTAL FEE: 1 $589.60 Revised: 07/04/201e1^ Xa rNj Li Xll ez, QJ N Z (D 0 zo cri >Lu .orw- --o o 106 M CL W 4) _a 0 crj 0 Cb coons E c t 0 m co w -E cl-.Cn > v:' ZS" E -a 0 0 co f CL fn 1A 1.1 CD 76 fZ) N-4 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CU PERTI NO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: OP A)QUGU iG PERMIT# OWNER'S NAME: h vvl A,) e; PHONE # GENERA VV— NESS LICENSE # WO 56, ADDRESS: 3' - /�/V e L CITY/ZIPCODE: f1✓ *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND UBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: — Signature Date Please check applicable subcontractors and complete 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 He Owner/ tractor Signature Date