11060163CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10535 SAN FELIPE RD CONTRACTOR•_ PERMIT NO: 11060163
OWNER'S NAME:
, J
PHONE NO:
Er LICENSED CONTRACTOR'S DECLARATION
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0S '9 Zf&
License Class Lic. # !JU l!/
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH F COMMERCIAL
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/ 604
Contractor A'N" 0' Date 2lZOL:2,
.RESIDENTIAL
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: CONVERT EXISTING LAUNDRY ROOM INTO GUEST
(commencing with Section 7000) of Division 3 of the Business & Professions
BATH(96SQFT) & RELOCATE LAUNDRY ROOM
Code and that my license is in full force and effect.
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
Sq. Ft Floor Area:
Valuation: $12000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. ItAPPLICANT
APN Number: 34222092.00
Occupancy Type:
CERTIFICATION
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 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature � Date �/ 3'd Z01 �
Issued by: - Date:
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
1 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:
I, 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:
[ 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
1 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. 1 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(x) should I store or handle hazardous material.
permit is issued.
Additionally, should 1 use equipment or devices which emit hazardous air
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
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forthwith comply with such provisions or this permit shall be deemed revoked.
// Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I 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 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
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.
Signature Date
Licensed Professional
���� CITY OF CUPERTINO
1 21 FEE ESTIMATOR - BUILDING DIVISION
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NOTF-- These fees aro hated an the nreliminary infnrmalinn availahle and are nn1v an owimalo_ Canlarl the Dent for izddn'1 infn_
FEE ITEMS (Fee Resolution 09-051 F, '. 7111/10)
ADDRESS: 10535 san felipe rd.
DATE: 06/20/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION: 1$12,000
%PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
Suppl. PC Fee: (E) Reg. 0 OT
PENTAMATION 1GENRES
PERMIT TYPE:
WORK convert existing laundry room into quest bath relocat laundry.
SCOPE
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NOTF-- These fees aro hated an the nreliminary infnrmalinn availahle and are nn1v an owimalo_ Canlarl the Dent for izddn'1 infn_
FEE ITEMS (Fee Resolution 09-051 F, '. 7111/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? Q Yes
E) No
$0.00
0 hours
$126.00
Plan Check, Hourly
ISTPLNCK
Suppl. PC Fee: (E) Reg. 0 OT
I0.0
hrs
$0.00
PME Plan Check:
$0.00
96 s.f.
$570.00
Remodel, Bath (<=300 so
IREMRESBAT
Permit Fee:
$0.00
Suppl. Insp. Fee4E) Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C:rwerfli-lion, 70
Acoustical Fee: 0 Yes (F) No
$0.00
Q
0
Work Without Permit? 0 Yes (E) No
$0.00
.Planning, Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
0
l's:rt1
Strong, Motion Fee: IBSEISMICR
$1.20
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2.20
$696.00
TOTAL FEE:
$698.20
Revised: 0412 9/2 01 1