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10070148 CITY OF CUPERTEgO BUILDING PERMIT BUILDING ADDRESS: 10181 CAMINO VISTA DR CONTRACTOR:JS MILLER PERMIT NO: 10070148 (' 'JER'S NAME: DALY CITY,CA 94015 PHONE NO:(408)674-2306 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.#�� ► MECH r RESIDENTIAL r COMMERCIAL Contractor Date 2� I hereby affirm that I am h a sed under the provisions of Chapter 9 JOB DESCRIPTION:CONVERT ROOM(MASTER)TO 2 BEDROOMS(20SQ);NO (commencing with Section 7000)of Division 3 of the Business&Professions RE-ROOF&NO STRUCTURAL 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 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 Sq.Ft Floor Area: Valuation:$3500 permit is issued. APPLICANT CERTIFICATION APN Number:34214087.00 Occupancy Type: 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 PERMIT EXPIRES IF WORT{IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source r la'ons per a Cupertino Municipal Code,Section 9.18. ilk Issued by ` --- Date.. Si --�ture Date ❑ O -BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous'material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined b the Ba Area Air y y Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or an orize —7(2,,1 16 forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION C RUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name u- ie above mentioned property for inspection purposes.(We)agree to save i, ify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address cons,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO Fm_1 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: 'VALUATION: 1$3,500 'TERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Du lex USE: p OVER THE COUNTER? © Yes O No APPLICATION 1 R3SFDADD/REM TYPE: MECHANICAL CI Y'es (j) No PLizMBING Q Yes. 01 No :ELECTRICAL Q Yes Q No �W a 00 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s .ft. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,III-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 $0.00 r7. T-T-1 77 NOTE: These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 09-051 E : 7/1/09) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 20 l.f. $443.00 Interior Partitions 1PARTIR-30 Suppl. PC Fee: Q Reg. Q OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 7� $42.00 Electrical IBREMRECEP Recep/Switch/Outlets Permit Fee: $0.00 Suppl. Insp. Fee: Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $42.00 7 ( on.+tructrcur 7(,tk I 1 Acoustical Fee: Q Yes Q No $0.00 Q 0 Work Without Permit? Q Yes (E) No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure Q Q Travel Documentation Fee: ITRAVDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $85.501 $485.00 TOTAL FEE: $570.50 Revised: 6/30/2010