10080149 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10260 VICKSBURG DR CONTRACTOR:LUCY SHEEN PERMIT NO: 10080149
OWNER'S NAME: 10260 VICKSBURG DR DATE ISSUED: 11/01/2010
OWNER'S PHONE: CUPERTINO,CA 95014-3320 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class Lic,# ADD 608 SQ FT TO LIVING,RELOCATE BEDRM#4
CONVERT
Contractor Date TO GUEST SUITE,REMODEL 200 SQ IN KITCHEN, 100 SQ
I hereby affirm that I am licensed under the provisions of Chapter 9 FT BATH 990 SQ FT THROUGH OUT UPGRADE PANEL&
(commencing with Section 7000)of Division 3 of the Business&Professions AND
Code and that my license is in full force and effect.
1 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:$120000
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 APN Number:36914011.00 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 S 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 LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, V costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: Z/-
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-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,1 agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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). 1 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 1 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 1
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 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this l'
Owner or authorized agent: Date:
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 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
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
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10260 Vicksburg Dr. DATE: 08/20/2010 REVIEWED BY:
APN: BP#: `VALUATION: Iso
FPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Du lex OVER THE PENTAMATION 1 R3SFDW
USE: p COUNTER? 0 Yes 0 No PERMIT TYPE:
WORK
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE 1D BP FEES BP FEE ID
CONSTR. s.f.
R-3 (Custom) II-B,III-B,IV,V-B 608 $2,349.00 1R3PLNCK $1,474.00 1R3INSP
TOTALS: 608 $2,349.00 $1,474.00
MECH,HOURLY 0 Yes 0 No PLUMB,HOURLY O Yes (D No ELEC,HOURLY 0 Yes Q No
Xh,ch, Plan Check Plumb. Plan Check Elegy. Plan(.'hack
Mech. Permit Yee: Phimh, Permit Fee: Ele(. Pcrnlir Fee:
Oihei•R1ech, Insp. 01her Plumh Insp, Other F,lec. Ins'p,
E17-
Pcch. Insp. /(. plumh. hisp. Fee. L°lec. Insp. Fec'
NOTE. These ees are based on the prefindnary in ormation available and are only an estimate. Contact the De t or addn I info.
FEE ITEMS (Fee Resolution 09-051 E . 7/1/10) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $2,349.00 200 s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 $570.00 1REMRESKIT
PME Plan Check: $0.00 100 s.f. Remodel,Bath(<=300 sf)
Permit Fee: $1,474.00 $570.00 /REMRESBAT
Suppl. Insp. Fee.{' Reg. 0 OT 0.0 1 hrs $0.00 990 s.f. Remodel,Other
PME Unit Fee: $0.00 $569.00 1REMRESI
PME Permit Fee: $0.00
Consiruction Tax
Acoustical Fee: 0 Yes 0 No $0.00 Q
Work Without Permit? Q Yes 0 No $0.00 0
Planning Fee: PLLONGRNGR $79.04 Select a Non-Residential E)
Travel Documentation Feces: Building or Structure O
Strong Motion Fee: $0.00 Select an Administrative Item
Bldg Stds Commission Fee: $0.00
SUBTOTALS: $3,902.04 $1,709.00 TOTAL FEE: 1 $5,611.04
Revised: 8/17/2010