10080095 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1141 DERBYSHIRE DR CONTRACTOR:ELITE HOME PERMIT NO: 10080095
DEVELOPMENT
OWNER'S NAME:
SAN JOSE,CA 95128; PHONE NO:(408)848-8370
13LICENSED CQNTRA TOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lia# S �' ADD 137SQ,NEW ENTRANCE & EXTEND KITCHEN& AT
/ jj// ) f�O �� REAR,351SQ NEW MASTERROOM& EXTEND FAMILY
Contractor / tfr`M4 Date ROOM &
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 REMODEL GARAGE,OPEN DOOR/WINDOW& REPLACE
(commencing with Section 7000)of Division 3 of the Business&Professiol is DOOR&
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declara ions:
1 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.Fi Floor Area: Valuation:$120000
1 have and will maintain Worker's Compensation Insurance,as provided for b
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36219021.00 Occupancy Type:
permit is issued. -
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information i; PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws n4ating 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,judgme its,
costs,and expenses which may accrue against said City in consequence of the Issued by: Date: �v Je/_6
dl
granting of this permit. Additionally,the applicant understands and will comely
with all non-point source regulations per the Cupertino Municipal Code,Sect on
9.18.
J A RE-ROOFS:
Signature Date /` I r` f' 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.
J 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.70,4,
Business&Professions Code)
1,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
1 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
1 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 I his Owner or authorized agent: �'r^ Date:----,---+—!
permit is issued.
I certify that in the performance of the work for which this permit is issued,! 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 exempt on,I
become subject to the Worker's Compensation provisions of the Labor Codt,I must 1 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoke d. 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 informatior 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,judgwents,
sts,and expenses which may accrue against said City in consequence of tie I understand my plans shall be used as public records.
ranting of this permit.Additionally,the applicant understands and will comply
.With all non-point source regulations per the Cupertino Municipal Code,Se-Aion Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FM_7 FEE ESTIMATOR — BUILDING DIVISION
ADDRESS:
DATE:
REVIEWED BY:
APN:
BP#:
*VALUATION:
1$120,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
OVER THE
COUNTER. 0 Yes 0 No
APPLICATION 1 R3SFDW
TYPE:
WORK
SCOPE
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-B,IV,V-B
512
$2,349.00
IR3PLNCK
$1,474.00
IR3INSP
TOTALS:
512
$2,349.00
$1,474.00
MECHANICAL 0 YFT
0 N
PLUMBING 0 Yes 0 Eo
[ELECTRICAL 0 Yes Q No
cch. Plan C ;%,,
Plumb. Ptun Cliec k
L.; . Non <-fl� ck
Xlech, Tice.Ph.cm)1,
Permil Pre:
/�h�c. Pe+7ra i/ 1"Ce
Other .tic+ 7r. PPh.'mh
Inv"
Other Eilec. b""p,
hmp. E'c:e..
hasp. i'C'r"
Eslc(. insp, l'c'c"
NOTE: These fees are based on the Preliminary information available and are only an estimate. Contact the Dept for addn'l info.
ov
FEE ITEMS (Fee Resolution 09-051 E . 711110)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,349.00
135 s.f.
$570.00
Remodel, Bath (<=300 sf)
IREMRESBAT
Suppl. PC Fee: 0 Reg. 0 OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
98 s.f.
$570.00
Remodel, Kitchen (<=300 sf)
IREMRESYIT
Permit Fee:
$1,474.00
Suppl. Insp. Fee:O Reg. 0 OT
0.0
hrs
$0.00
255 s.f.
$380.00
Remodel, Other
IREMRESOTH
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
77EFs.f.
$221.00
Re -roof
IREROOFRES
Con.�lrztc con '717,r
Acoustical Fee: 0 Yes 0 No
$0.00
0
0
Work Without Permit? 0 Yes 0 No
$0.00
Plannin Fee: PLLONGRNGR
$66.56
Select a Non -Residential
Building or Structure
0
0
7-1-urel 170C7nnC'rrfCtl70Y! Fet'a:
Strong Motion Fee: IBSEISMICR
$12.00
Select an Administrative Item
Bldg; Stds Commission Fee: IBCBSC
$5.00
SUBTOTALS:,
$3,906.56
$1,741.00
TOTAL FEE:
1 $5,647.56
Revised: 8/12/2010