10070192 CITY OF CUPERTI'NO BUILDING PERMIT
BUILDING ADDRESS: 20292 NORTHCOVE SQ CONTRACTOR.-T-B - E PERMIT NO: 10070192
OWNER'S NAME: COLIN CAMPBELL w)wo DATE ISSUED:07/29/2010
.'NER'S PHONE: 4084463009 l 06%6" CAf_�-P'>C I I PHONE NO:
4Jr LICENSED CONTRACTOR'S DECLARATION
,,//�� BUILDING PERMIT INFO: BLDG� ELECT I— PLUMB
License Class L/C! CWO
)Lic.# F_
Contractor —
r�_ LA,+% �01O MECH RESIDENTIAL COMMERCIAL
�`'�d lcl!L_ Date a
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMODEL 90 SQ FT TO KITCHEN,REPLACE
(commencing with Section 7000)of Division 3 of the Business&Professions ELECTRICAL,NEW HOOD
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. Sq.Ft Floor Area: Valuation:$30000
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
L APN Number:31641073.00 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 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,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 Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
7—,-2,q 2v(o 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,I 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
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,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. 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 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 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this �C! CD
permit is issued.
Owner or authorized agent �� ,:� Date:
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
-n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
nnify and keep harmless the City of Cupertino against liabilities,judgments,
cults,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: 20292 Northcove Sq. DATE: 07/29/2010 REVIEWED BY: jsg
APN: BP#: *VALUATION: 1$30,000
=PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Remodel, Kitchen (300 s.f. max)
PRIMARY Residential APPLICATION 1 R3SFDADD/REM
USE: f)'t,t(_ : .`,E: TYPE:
aww Kitchen replace electrical new hood
0C
3U
FE E ID
1 REM RESKIT
NOTE: Thesefees are based on the preliminary in ormation,ivailable and are only an estimate. Contact the De t or addn7 info.
FEE ITEMS (l ee Resolution 09-051 Ef' %:1%09) FEE QTY/FEE MISC ITEMS
f
fl p kA='
Permit Fee: $570.00
#f 'Z IT
F.
Work Without Permit? Q Yes (D No $0.00
Strong Motion Fee: IBSEISMICR $:3.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $2.00
SUBTOTALS: $575.00 $0.00 TOTAL FEE: $575.00
Revised: 7/27/2010
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot :
APN . . . . . . . . : 31641073 . 00
DATE ISSUED. . . . . . . : 07/29/2010
RECEIPT #. . . . . . . . . : BSC00011015
REFERENCE ID # . . . : 1OC70192
SITE ADDRESS . . . . . : 20292 NORTHCOVE SQ
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : COLIN CAMPBELL
ADDRESS . . . . . . . . . . : 20292 NORTHCOVE SQ
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-0562
RECEIVED FROM . . . . : LESLIE LAMCKE
CONTRACTOR . . . . . . . : TBE - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBE - TO BE DETERMINED
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY TMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 30, 000 . 00 2 . 00 0 . 00 2 . 00 0 . 00
1BSEISMICR VALUATION 30, 000 . 00 3 . 00 0 . 00 3 . 00 0 . 00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00
1REMRESKIT SQ FEET 1 . 00 570 . 00 0 . 00 570 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 689 . 00 0 . 00 689 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 689. 00 visa
---------------
TOTAL RECEIPT 689. 00
CITY OF C"UPERTINO
ILE ADDITION/REMODEL
CUPERTINO FEE SCHEDULE
APN# 3 LP 41 Date:
Is a 2" unit being added? Yes ❑ No ❑ If yes, �Aease fill out the permit application for 2" unit.
Building Address: a O Q
Mailing Address (if different from building address):
Owner's Name: C kll (G 04*// Phone# : &c9k) 4"P q `f G 3 c--,o R
Contractor: L1*4 LQ,4 dc' _ Phone#: (�f vs,2 7 7- ?6*:' I
1)6 Fax#:
Cupertino Business License: State Contractor License#: a d qD
Contact: i4c,,d L-d ct. Phone#: �-1 oir 3 77- 7c, 1
Fax#:
Landscape Ordinance Compliance:
Landscape area in sq. ft. (includes all irrigated areas):
If 2,500 sq. ft. or less, compliance with the Landscape Water-Efficiency Checklist is required.
If more than 2,500 sq. ft., a complete Landscape P: oject Submittal is required.
Compliance Method: ❑ Plant Type [] Water Budget
Building Permit Info:
Bldg. N. Elect. 31 Plumb. ® Mech. 0 Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including addition)"
/2t p1a,e_ ale - ; I Poi-)
a
Remodel Includes Re-Roof Yes ❑ No g If yes list number of squares
Remodel Includes Structural: Yes ❑ No 2_
Do you have the pre-application planning approval? Yes ❑ No ❑
If yes, please provide a copy of your planning ipproval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen \ Bath ether
Type of Construction (Usage Class): Occupancy T4pe:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-13 Valuation: O, coc"o, 00
Please check this box if the project is a
Project Size: Express ❑ Standard [9 Lar e ❑ N a'or ❑ second-story addition ❑
Please complete relevant portion of the Green Buil ding
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set& the sheet index.
Revised C 5/18/10
102- 91 " DP,
C-UPERTimc CASS014
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