13040092 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20290 PACIFICA DR CONTRACTOR �j+ �° (�'Q/}�'r PERMIT NO:13040092
OWNER'S NAME: TANAKA JOHN S AND AMY Y ET AL DATE ISSUED:04/11/2013
OWNER'S PHONE: 4082195275 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class
Lic.# � �_ RECONFIGURE MASTER BATH&REMODEL&RETILE
AND
Contractor_'3f49-JZ e C&ft Date q;&o / 3 CHANGE FIXTURES IN HALL BATH
I hereby affirm that I 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.
I hereby affirm under penalty of perjury out 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:$15000
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 APN Number:36944012.00 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 ente
upon the above mentioned property for inspection purposes. (We)agree to save' ;0 DAYS AST CALLED INSPECTION.
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 1-3
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
�yRE-ROOFS:
Signature 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.
❑ 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
I,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 .
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. 1 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,Sections 2 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: /C7
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 CONSTRUCTION LENDING AGENCY
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 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 thatthe 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
indemnify 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
V
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333-building(a)cupertino.ora
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESSAPN#
a r 77 U
OWNER NAME PHO ca— E-MAIL
�
STREET ADDRESSr CITY,STATE,ZIP CA 9s�! FAX
2-02,qoCONTACT NAME PHONE E-MAIL
art ��?y - ` oal3
STREET ADDRE _20 M AIF-117S CITY,STATE,ZIP I FAX
❑OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAI E r LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANYN E E-MAIL FAX
_r?64e c
STREET DDRESS CITY,STATE Z[P pg0NE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
3e- 04
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA/
V REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA; DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES "SECOND STORY ❑YES
BEQNADDED? ONO ADDITION? ONO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF - ISTHEBLDGAN ❑YES TOTALVALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO 0�
By my signature below,I certify to each of the following: I am the property owner or authorized agent t ne property owner's behalf. I have rea 's-
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building nsiPction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: G r- Date: `-t'
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for El OVER-THE-COUNTER El BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD El PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR El SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B ldgApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS:.20290 PACIFIC DR DATE: 04/11/20137] REVIEWED BY: MELISSA
APN: 369 44 012 BP#: *VALUATION: $15,000
*PERMIT TYPE: Building.Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Du lex PENTAMATION 1 R3SFDREM
USE: p PERMIT TYPE:
WORK RECONFIGURE MASTER BATH & REMODEL& RETILE AND CHANGE FIXTURES IN HALL BATH
SCOPE
u m. _
N
Mech.flan Check PlnmL Plan Check Dec.Plan(:;heck
A-tech. Permit Fee: Plumb.Permit Fee: F.lec.Permit fee:
Other;llecrh.Inst}. Other Plumb Insp. Other Elec.Insp.
Alech.Insp. Fee:.- Plumb. Insp.Fee: Elec.Insp,fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-653 E . 7ff 11/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F120 1 s.f. Remodel,Bath(<=300 sf)
Suppl.PC Fee: (2) Reg. 0 OT 0.0 hrs $0.00 $600.00 1REMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee-.E) Reg. ® OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consiruclion Tim:
Administrative.Fee:
Work Without Permit? ®Yes (E) No $0.00 1 0
Advanced Planning Fee. $0.00 Select a Non-Residential 0
Travel Documentation Fees: Building or Structure
Strong Motion Fee: 1BSEISMICR $1.50 Select an Administrative Item.
Bldg-Stds Commission Fee IBCBSC $1.00
s
602.50
$2.50 $600.00
Revised: 04/01/2013
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Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTORLIST;
JOB ADDRESS: ^02 O PERMIT# >. 30
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR: ,e 2wc BUSINESS':LICENSE*
ADDRESS:X-0 9—)-o A ' CITY/ZIPCODE
*Our municipal code requires all businesses w rking in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL:BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED"-A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Sijinaturr Date
Please check applicable subcontractors.and complete the following information
V 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
Owner/Contractor Signature Date