10090092CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1169 HUNTERSTON PL CONTRACTOR: NEW WORLD BUILDER PERMIT NO: 10090092
OWNER'S NAME: P
AN JOSE, CA 95122 PHONE NO: (408) 472-3692
0 LICENSED CONTRACTOR'S DECLARATION
License Class C!J Lic. # 12.'5 d 9 'f-
Contractor ~)euJ ltJc>dJ bl2iRcle.Pate /0.. L_lo
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 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 ofthe work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 ofthe 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.
Signature Date to -,c:.. (()~~lJl9
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner ofthe 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).
I 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 ofthe 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 ofthe 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 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.
Signature Date
rBUILDING PERMIT INFO: BLDG r ELECT r PLUMB
rMECH RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: ADD (352SQ) FAMILY ROOM ON EXISTING FAMILY
ROOM;
NO RE-ROOF & NO STRUCTURL
Sq. Ft Floor Area: Valuation: $30000
APN Number: 36221018.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date:
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
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I 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 I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owl 'h;.,
ONSTRUCTION LENDING AGENCY
I 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
1 mADDRESS:.'
APN:
*PERMIT TYPE: Building Permit
PRIMARY SFD or DuplexUSE:
WORK
SCOPE
CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
REVIEWED BY:
I BP#:
I DATE:
'VALUATION: 1$30,000
I PLAN CHECK TYPE: Alteration / Addition / Repair
PENTAMAnONIOVER THE 'IR3SFDADDCOUNTER? QYes 0No PERMIT TYPE:
OCCUPANCY TYPE: TYPE OF
CONSTR.
FLRAREA
(s.f,) PC FEES PC FEE ID BP FEES BP FEE ID
R-3 (Custom) II-B,III-B,IV,V-B 352 $1,438.00 lADDPLCK $1,169.00 lADDINSP
TOTALS: 352 $1,438.00 $1,169.00 I
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn 'l info.
FEE ITEMS (Fee Resolution 09-051 Etf 7inO) FEE QTYIFEE MISCITEMS
Plan Check Fee: $1,438.00 Select a Misc Bldg/Structure
Suppl. PC Fee: o Reg. Q OT I 0.0 I hrs $0.00 I or Element of a Building
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp. Fee:0 Reg. Q OT I 0.0 I hrs
$1,169.00
$0.00
I
PME Unit Fee: $0.00 I
PME Permit Fee: $0.00
( 'uns r!'!lct ion 1:\ I I I
Acoustical Fee: QVes eNo $0.00 Q
Work Without Permit? QVes 0No $0.00 I 0
Planning Fee: PLLONGRNGR $45.76 Select a Non-Residential 0
ro, / \)( ." I Building or Structure Q
.olIII
Strong Motion Fee: IBSEISMICR $3.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
SUBTOTALS:
$2.00
$2,657.76 $0.00
I
TOTAL FEE: I $2,657.76
Revised: 9/14/2010