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11010092CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22432 BALUSTROL CT CONTRACTOR: PERMIT NO: 11010092 OWNER'S NAME: LEE COLLINGS Ti L DATE ISSUED: 01/18/2011 OWNER'S PHONE: 4084462109 PHONE NO: Li LICENSED CONTRACTOR'S DECLARATIONr' r BUILDING PERMIT INFO: BLDG ELECT 6- SCj' (� Q y � PLUMB License Class ic. # / (o 1 MECH r— RESIDENTIAL F_ COMMERCIAL r Contractor !/ 1. <9L Date / I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMODEL MASTER BATHROOM (34SQ);NO RE -ROOF & (commencing with Section 7000) of Division 3 of the Business & Professions NO STRUCTURAL 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. 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: $5000 permit is issued. /�'" APPLICANT CERTIFICATION p APN Number: 35603017.00 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 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 regulatio s per the Cupertino Municipal Code, Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date / ' ,�^-� Issues-ny: Date: �/,�� OWNER -BUILDER DECLARATION I 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: constrict the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 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. I will maintain Section 3700 of the Labor Code, for the performance of the work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 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 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, I Health & Safety Code, Sections 25505, 25533, and 25534. become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner i i home get l Date: 1 / 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 work'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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, 's, and expenses which may accrue against said City in consequence of the Lender's Address ing of this permit. Additionally, the applicant understands and will comply *yin 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 CD O DC7 CD C= CCD CCD CCD CDD -u -�-C)�� u uuuu PD 9PPCCD) { CCDD CD CD CD Cp CD x X x x cn ., cQ - O cp CAM cn (M an cio cmcn O �. =:r O c -mo n ccn Q O C cn oo CD K7' ami O CD O Cn CD v� O DC7 CD C= CD -0-ucm { CCDD CD CD Cp CD cn ., cQ - O cp o O O CID--, CD c -mo n ccn Q Q cn oo CD K7' ami X -a C CD cQ Q CD cn co w cn cn 0 MORM SEE DURSIX9 Meal CITY OF CUPERTINO 3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35603017.00 DATE ISSUED.......: 01/18/2011 RECEIPT #.........: BS000012500 REFERENCE ID # ...: 11010092 SITE ADDRESS .....: 22432 BALUSTROL CT SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: LEE COLLINGS ADDRESS ..........: 22432 BALUSTROL CT CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: MICHAEL M FULLER CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096 COMPANY ..........: TBD - TO BE DETERMINED ADDRESS .......... CITY/STATE/ZIP ...: , TELEPHONE ........ FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- ----------------------- 1BCBSC VALUATION ---------- 5,000.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 0.00 1BSEISMICR VALUATION 5,000.00 0.50 0.00 0.50 0.00 1REMRESBAT SQ FEET 1.00 570.00 0.00 570.00 0.00 TOTAL PERMIT ---------- 571.50 ---------- 0.00 ---------- 571.50 ---------- 0.00 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Deptfor addn'1 info. FEE ITEMS (Fee Resolution 09-051 Ef. 7%1:-10) ADDRESS: 22432 balustrol ct. DATE: 01/18/2011 REVIEWED BY: bobs. VI"'ch. I'y 'Y'rt! l f'i'i': APN: BP#: *VALUATION: 1$5,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: I PENTAMATION 1 R3SFDREM I PERMIT TYPE: WORK remodel existing bathroom non structural SCOPE Suppl. Insp. Fee.0 Reg. ® OT NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Deptfor addn'1 info. FEE ITEMS (Fee Resolution 09-051 Ef. 7%1:-10) Lft�ch. F'hrn ('Ite ck 1'hirrrt�. f'loo C'`?r t'4 i hL'C'k VI"'ch. I'y 'Y'rt! l f'i'i': l'r1 n"11 I't't` t!l %'c't' 7' IC( P'Ir crit Oilicr dfech. hjsp. {}Fuer' Plum/, Irtsh.Li 0111 r 1,17ec My, Lj 31c, h. In,1z /''v 1"17 1h hi'vp' f cc' I'lo , 117sp. Fcc: NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Deptfor addn'1 info. FEE ITEMS (Fee Resolution 09-051 Ef. 7%1:-10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 =s.f. Remodel, Bath (<=300 sf) $570.00 IREMRESBAT Suppl. PC Fee: 0 Reg. ® OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.0 Reg. ® OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ('011S11-11C1ion lira Acoustical Fee: 0 Yes (E) No $0.00 E) Work Without Permit? 0 Yes 0 No $0.00 Planning Fee: $0.00 0 I 11-a el 00C'111w"Itatlot'! /'t'.E'.i'; Strong Motion Fee: IBSEISAHCR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.501 $570.00 TOTAL FEE:: $571.50 Revised: 01/03/2011 CITY OF CUPERTINO ADDITION/REMODEL FEE SCHEDULE APN#Date: �3 -5 0 3 D 11 Is a 2° unit being added? YesEJ Nof yes, please fill out the permit application for 2° unit. Is this a 2°d story Addition? Yes ❑ No [l Is this house an Eichler? Yes No If yes, needs Planning approval. Building Address: ZZC �- CA c'.5 0 / q,32 eflk'Ao Mailing Address (if different from building address): Owner's Name: Phone # .� C tin 0 S q 1 �o ' V 0 Contr ctor: Phone #: 'lp $ s/ y 15-q.7 t e-, Ir.Ti Fax/e-mail: �,� }� Y►�a� . Cupertino ess License---.-, State Contractor License '#: 1Busi '4609 Contact: Phone #: Fax /e-mail: Landscape Ordinance Compliance: Landscape area in sq. ft. (includes all irrigated areas): If 2,500 sq. ft. or less, compliance with the Landscape Water -Efficiency Checklist is required. If more than 2,500 sq. ft., a complete Landscape Project Submittal is required. Compliance Method: Plant Type ❑ Water Budget Building Permit Info: Bldg.lect. 0 Plumbing x Mechanical Z Hillside Project Size: Counter Ex ress ❑ Standard ❑ Large . ❑ Major ❑ Job Description: Addition -What is being added?(Be Specific): What is being remodeled (not including addition)? maLOf-r bad r©o Yv\ —nu,? .�fi2 Remodel Includes Re -Roof: Yes ❑ No 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 3 1V 19 Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B [ Valuation: 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. 1 &7711