09100040 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10471 STOKES AVE CONTRACTOR:CALIFORNIA BATHROOM PERMIT NO:09100040
&KITCHEN
C R'S NAME: CROSBY 1261 LINCOLN AVE STE 204 DATE ISSUED: 10/06/2009
OWNER'S PHONE: 4083938931 SAN JOSE,CA 95125 PHONE NO:(408)360-9700
LICENSED CONTRACTOR'S®DECLARATION BUILDING PERMIT INFO: BLDG ELECT F PLUMB
License Class Lic.# ,� l C� / V9
/^ ��^ {� �_•'�s �� �,,,,,1, ��� - MECH� RESIDENTIAL� COMMERCIAL�
Contractof�Yyn1� 4 v a"4 '�O-�'�"" ate a -'�
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:MASTER BTH SHOWER REPLACEMENT LAV
(commencing with Section 7000)of Division 3 of the Business&Professions AND COUNTER
Code and that my license is in full force and effect. REPLACEMENT;NO RE-ROOF&NO STRUCTURAL(45SQ);
CAFLIRONAI BATHROOM&KITCHEN REWD BUS LIC
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.
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 Sq.Ft Floor Area: Valuation:$15000
permit is issued.
APPLICANT CERTIFICATION APN Number:32647028.00 Occupancy Type:
1 certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180YS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ,. /C).� 'O.L�
/ It4 b �� Issued b7,*,-, / Date:
❑ te
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by 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 J store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I l /
G/
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. ate:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is 1 hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to' 'ling construction,and hereby authorize representatives of this city to enter Lender's Name
e above mentioned property for inspection purposes.(We)agree to save
;i.,-:unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10471 STOKES AVE CONTRACTOR:CALIFORNIA BATHROOM PERMIT NO:09100040
&KITCHEN
OWNER'S NAME: CROSBY 1261 LINCOLN AVE STE 204 DATE ISSUED: 10/06/2009
OWNER'S PHONE: 4083938931 SAN JOSE,CA 95125 PHONE NO:(408)360-9700
LICENSED CONTRACTOR'S DECLARATIONF
Q 7 BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class__ Lie.# F_
MECH RESIDENTIAL COMMERCIAL
Contracto i' �. .P ✓�- bate a - +'
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:MASTER BTH SHOWER REPLACEMENT LAV
(commencing with Section 7000)of Division 3 of the Business&Professions AND COUNTER
Code and that my license is in full force and effect. REPLACEMENT;NO RE-ROOF&NO STRUCTURAL(45SQ);
CAFLIRONAI BATHROOM&KITCHEN REWD BUS LIC
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.
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 Sq.Ft Floor Area: Valuation:$15000
permit is issued.
APPLICANT CERTIFICATION APN Number:32647028.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 D YS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signa t_�-- /— 13a� �� b-;o I Issued b J'S /�"L 'a? Date:
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,1 agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
1 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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
1 have and will maintain Worker's Compensation Insurance,as provided for by 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 I use equipment or devices which emit hazardous air
1 certify that in the performance of the work for which this permit is issued,l shall contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 2554.
Compensation laws of California. If,after making this certificate of exemption,1 /
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. ate:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is 1 hereby affirm that there is a construction lending agency for the performance of work's
correct.l agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18• I understand my plans shall be used as public records.
Signature Date Licensed Professional
C(3 .10 0c!�L --C)
CITY OF CUPERTINO
h ADDITION/REMODEL
CUPERTINO PERMIT APPLICATION FORM
APN # ,22-U -7 c)z-k I c Date: /
� G
Is a 2° unit being added? Yes 1:1 No If yes, please fill out the permit application for 2" unit.
Building Address:
1 0 � 1 �.To A21 AV
Mailing Address (if different from building address):
Owner's Name: Phone #
Contractor: nn j / Phone#: y O-9 - 3 6" — �'-7 o a
C41, f o;plu l �Y�'b�.n lean �ro�?`P"1 Fax #: -- 3 6 a -7 4 7
Contractor License #: 6 IRS 71 8
Cupertino Business License #: 2 /16
Contact: Phone#: 3 ? 6
Fax #:
Building Permit Info:
Bldg. ❑ Elect. ❑ Plumb. Mech. ❑ Hillside ❑
Job Description: 0VlA5T6� JS�4 -660 G'A- WL4:6m
Addition-What is being added?(Be Specific): 4M)
G�� r .�
What is being remodeled (not including addition)? /fc e
i.
d- e. S q e_ �o C4 -h,b.�r { 4) `I✓bo-,4_
Remodel Includes Re-Roof. Yes ❑ No J�j If yes list number of squares
Remodel Includes Structural: Yes ❑ No
Do you have the pre-application planning approval? Yes ❑ No ❑
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath Other
Type of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ IUIIUV-A ❑ IUIII B, IV-HT, V-B ❑ S F.•
Valuation: �,�0'-, Please check this box if the project is a
second-story addition ❑
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set & the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 07/06/09
CITY OF CJ]PERTINO
ADDITION/REMODEL
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
ADDITIONS 1R3SFDADD
1PLLONGRNGR Long Range PL
Planning/Residential
1R3INSP Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1R3REPPLNC Dwellings Repeat Plan B
Check
1R3HI14SP Dwellings Hillside B
inspection
1R3HPLNCK Dwellings Hillside plan B
check
1R3HREINSP Dwellings Hillside. B
Repeat Inspectiori .
1R3HREPLNC Dwellings Hillside B
Repeat Plan Check
1R3ALTINSP Dwellings Alternate B
Materials Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check
IPCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
Disposal System
I PRSEWER Sewers P
1BPSPRINK Lawn Sprinkler/Backflow P
IBPWSVCS Main Water Service P
1 BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE SeismicResidential B
1REROOFRES Residential Re-roof Each B
100 SF