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11010078 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11387 LINDY PL CONTRACTOR:FARBEX PERMIT NO: 11010078 CONSTRUCTION SERVICES OWNER'S NAME: YEHOSHUA ROM 1093 KELLY DR DATE ISSUED:01/13/2011 INER'S PHONE: 4084290404 SAN JOSE,CA 95129 PHONE NO:(408)590-5410 LICENSED CONTRACTOR'S DECLARATION I 6, �zl BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class y� Lic.#! �✓ MECH[_ RESIDENTIAL f— COMMERCIAL Contractor FI!"Etc(2D/l/_QF RV tt Date___&t 7Z11 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMODEL 72 SQ FT TO BATHROOM,ELECTRICAL OUTLETS (commencing with Section 7000)of Division 3 of the Business&Professions IN SAME LOCATION 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:$7846 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 this APN Number:35624002.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I 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 INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, J costs,and expenses which may accrue against said City in consequence of the Issued by: Date: granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. _ RE-ROOFS: Signatur 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. 1] 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. I 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 I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secf 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this j permit is issued. Owner or authorized age t: Date: 3 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 CONSTRUCTION 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 demnify and keep harmless the City of Cupertino against liabilities,judgments, costs,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 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 11378 lindy place DATE: 01/13/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $7,846 R*PERMITT'YPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY ----[PENTAMATION 1 R3SFDREM USE: SFD or Duplex PERMIT TYPE: WORK bathroom remodel non strucural add outlets at living room location SCOPE 1 fs dr £'1an Ch,(k 11ho,ib. 11/mi Ch-c1 Elec.Plan Check 0.0 hrs $0.00 tt� I. F of nrr 1'ce: llww" I Elec.Permit Fee: 1EPERMIT o ho'Ak"h. ln'v' fn—p Other Elec.Insp. 0.0 �rs $42.00 l h. If,.y. 1,CC: 1'irrutt'- Il'jp, rt,,. klc ' limp. i�'v NOTE. Thesefees are based on the preliminairTv in ormation available and are only an estimate. Contact the De t or addh 7 info, FEE ITEMS (Fee Resohition 09-05I E . 7%1i70j FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 =1s.£ Remodel,Bath(<=300 sf) Suppl. PC Fee: 0.0 hrs Reg. ® OT $0.00 $570.00FREMRESBAT PME Plan Check: $0.00 ® Electrical Permit Fee: $0.00 $42.00 1BREMRECEP Recep/Switch/Outlets Suppl. Insp.Fee{0 Reg. ® OT0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $42.00 (",onso-11( ion Acoustical Fee: 0 Yes 0 No $0.00 0 Work Without Permit? 0 Yes 0 No $0.00 E) Planning Fee: $0.00 0 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.78 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.001 1 SUBTOTALS:' $85.781 $612.001 TOTAL FEE: $697.78 Revised: 01/03/2011 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35624002 . 00 DATE ISSUED. . . . . . . : 01/13/2011 RECEIPT #. . . . . . . . . : BS000012477 REFERENCE ID # . . . : 11010078 SITE ADDRESS . . . . . : 11387 LINDY PL SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : YEHOSHUA ROM ADDRESS . . . . . . . . . . : 11387 LINDY PL CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4814 RECEIVED FROM . . . . : FARBEX CONT CONTRACTOR . . . . . . . : GREGORY WNOROWSRI LIC # 29686 COMPANY . . . . . . . . . . : FARBEX CONSTRUCTION SERVICES ADDRESS . . . . . . . . . . : 1093 KELLY DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95129 TELEPHONE . . . . . . . . : (408) 590-5410 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 7, 846 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BREMRECEP NO. OUTLETS 4 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1BSEISMICR VALUATION 7, 846 . 00 0 . 78 0 . 00 0 . 78 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1REMRESBAT SQ FEET 72 . 00 570 . 00 0 . 00 570 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 697 . 78 0 . 00 697 . 78 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 697 . 78 MC --------------- TOTAL RECEIPT 697 . 78 . Tt4 r,w M �,. M,�,�p�c �u��-' S� FCI II f 1 DB332135 WP GFCI O BATH 8'-4"x 9'-0" 0 k WP 01P 2668 coop CE WP = .j t LIVING AREA 88sgft ( iv C-d4 ou P FSC �b *HC l nPPH,,VFU IN ACA OPOAN(.i ..Ir'' ;HE CITY a' CUPS PTINO> +)+,f ANS )ORDINANE_f:_' DATE_ �����-�( r/ tJ�7 +' fj M SIGNS This set of pl .it+cations MUST be kept on the Iota at all times and It is iuv Pl--ACv unlawful to make any changes or alterations on same Without written permission from r„l pf Z-vb,rS C A Q 13�i� the Building Def`l.ib •Aril,and of Cupertino. l� ( 1. The stamping of r,�s �,lan and specifications SHALL NOT bt-,wi,-r permit or to he an CB C_ Capproval of the viola`-�i of any provisions Z ( U '�b (� of any Cltq i!rdu'..i'.,e u. ^I law �- C 2o �D f C 26 2 Building Department City Of Cupertino LM 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: ?j'9 LLk w L^ PERMIT# 111514�Z217ea— OWNER'S NAME: 5 U+3 Z o t�4 PHONE# t vl 42q —P b' GENERAL CONTRACTOR: A i~ 6c&57"c0 �j BUSINESS LICENSE# ADDRESS: 1,o c{ KZLL- r- >-a rJ 5E CITY/ZIPCODE: 34r%/ *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 ALL SUBCONTRACTORS 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: I/ 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 Tile � > 1 caner ontra nature Date CITY OF f CITY OF CUPERTINO ADDITION/REMODEL CUPERTINO FEE SCHEDULE APN# 2� 1 Wa 6U Date: ® I SCO `7 - I 12 j Is a 2" unit being added? Yes ❑ No f yes, please fill out the permit application for 2" unit. Is this a 2"d story Addition? Yes ❑ No Is this house an Eichler? Yes ❑ No If yes, needs Planning approval. Building Address: V k3 Fl--- L_� KM.. -P Mailing Address(if different from building address): Owner's Name: Phone# �v 2q ' 4 Contractor: Phone#: 4t e v Fax/e-mail: Cupertino Business License: State Contractor License#: Contact: , I Phone#: Lc o S�?to Sri r U vC� ¢ ( WKN CZ.Jw S Fax/e-mail: andscape 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. Com fiance Method: ❑ Plant Type ❑ Water Budget Building Permit Info: Bldg. Elect. Plumbing Mechanical Hillside Project Size: Counter Express Standard LarRe ❑ Major ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? q U ' c' 14 eG4FC i P_ic.4L Cc) L€i.4 k "*) LIP- S-CC 4 7 Ceti 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 s C Other Type of Construction (Usage Class): Occupancy Type: �-- 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B E!�' 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. �'