11010083CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22326 REGNART RD IDETERMINED BD - TO BE I PERMIT NO: 11010083
OWNER'S NAME:
'S DECLARATION
License Class 1% Lic. 4 ����� O
Contractor /— ZF-.zcp//
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.
1 hereby affirm under penally 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
permit is issued.
APPLICANT 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
9.18. -r
hereby affirm That 1 am exempt from the Contractor's License Law for one of
the following Iwo reasons:
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
construct the project (Sec.7044, Business & Professions Code).
1 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
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
permit is issued.
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
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.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above infonmation 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,
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
9.18.
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
r— r 1_ .
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: SFDWL DEMO FIREPLACE/CHIMNEY, REPAIR ROOF &
WALL
"SEE NOTES"
Sq. FI Floor Area: I Valuation: $12000
I APN Number: 36639007.00 I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DhAYS OF PERMIT ISSUANCE OR
180 DAYS BR AST CALLED INSPECTION.
Issued by:
Date: Zg-
RE-ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safely Code, Sections 25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
will maintain compliance with the Cupertino uuicipal Code, Chapter 9.12 and
The Health & Safety Code, SV.
or authorized agent: Date: ,
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature Date _
DEMOLITION
W"Iff,
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
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ADDRESS: 22326 regnart rd
DATE: 01/14/2011
REVIEWED BY: bobs.
�
APN:
BP#:
"VALUATION: 1$12,000
*PERMIT TYPE: Demolition Permit
hl.-i:� C1lccl rr,
PRIMARY
USE: SFD or Duplex
PENTAMATION
PERMIT TYPE: 1SFDWL-DE i
WORK
sfd demo fireplace/chimney,repair roof and wall.
SCOPE
FEE ID FLR AREA
S.f.
1DEMORES 1
:W Ji. flan Cicck
hNlech. Permit I e,�:
Plumh. Permit 1,
Other Mech. Insp:
Other Plumb Insp.L]
Other Elec. Insp. El
;Veeh. Insp. Fern
Plumb. hrap. Fcc:
Elec. Insp, Fee:
NOTE: These fees are based on the prelindnary information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check -Fee:
Suppl. PC Fee
Phrmh.1,11ech.!Elec Platt Check:
Permit Fee: ISUPINSFEE
$507.00
Suppl. Insp. Fee.0 Reg. 0 OT
1.0
hrs
$126.00
Phnnh.fdlcch.i'Elec Unit Fee:
Plurrth.;`GIc ch.iElec Permit Fee:
Construction .Tax
Acoustical Review Fee:
14"Ork- ffithout Permit"
Planning Fees:
A
/Tavel L)octonentalion Fees:
Strong Motion Fee: IBSEISMICR
$1.20
Select an Administrative Item
BldIZ Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$635.20
$0.00 TOTAL FEE:
1 $635.20
Revised: 01/03/2011