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13040111CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21772 COLUMBUS AVE CONTRACTOR: JEREMY MAO INC PERMIT NO: 13040111 OWNER'S NAME: TRICIA LIN 1 19935 SEAGULL WAY I DATE ISSUED: 04/15/2013 OWNER'S PHONE: 4082571225 ❑ LICENNSED CONTRACTOR'S DECLARATION License Class R7 Lie. # !3 41 jt- 2' Contractor jletL Mf ` <` D Ae Date 4 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 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 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 an d 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 ofd/ 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 ❑ 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 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 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 of the 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 of the 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 SARATOGA, CA 95070 I PHONE NO: (408) 449 -9942 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALS REPLACE TUB & TILE IN HALL BATH & ADD 2 (N) EXHAUST VENTS IN BOTH BATHS Sq. Ft Floor Area: I Valuation: $1000 APN Number: 35618040.00 1 Occupancy Type: PERMIT EXP RK IS NOT STARTED WIT DAY + PERMIT ISSUANCE OR AYS FROWILAST CALLED INSPECTION; %s //-3 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. Owner or authorized agent: Date: `> �r CONSTRUCTION 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 CCUPERTINO I I NF.W Cnwm i TCTTnw CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(a )cupertino.oro M AT)T1MOM I 1 ATTVDATTl1T. i/ rT F-1 r irrrr nnr�r. �b PROJECT ADDRESS C� SV Anwg (l APN # (� (/(f O A� I t%6 t P O d LL E-MAIL STREET ADD CITY, STATE, ZIP FAX CONTACT NAME / U ` PHONIk ` b b STREET ADDRESS CITY, STATE, ZIPS FAX OWNER ❑ OWNER- BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER I _k 5q � LICENSE TYPE BUS. LIC # C .6 T r a COMPANY NAME E-MAIL FAX STREET ADDRESS t 6 ` � U G� W f� `NAME J (7�� O % CITY, STATE, ZIP /� /� j �y C/f� J l� PHONE ARCHITECT/ENGINEER LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK �r, I r+ A J v�1 �� `a�✓ � �p� l 7 EXISTING USE PROPOSED USE CONSTR. TYPE # TORIES USE TYPE OCC. SQ.FT. VALUATION ($) AREA AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA f BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA // PORCH AREA DECK AREA TOTAL DECK /PORCH AREA GARAGE AREA: DETACH ❑ ATTACH I # DWELLING UNITS: IS A SECOND UNrr [].YES SECOND STORY ❑ YES BEINGADDED? ❑NO ADDITION? ONO CEIVED B TOTAL VALU Tlr, PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑YES EICHLER HOME? ❑ By my signature below, I certify to each of the following: I am the property owner or autho ' a ct on the property owner's behalf. I have read this application and the information I have provided is co t I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating ding constru I authorize representatives of Cupertino to enter the above - identified roperty for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP E3 OVER -TH &COUNTER El BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure E) STANDARD El PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to _ submittal of Building Permit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06121111 CITY OF CUPERTINO '"'Flin 170rrTra A rIP9,1113 WITIT "IN!"_ nlVI'QFnN Mech. Plan Check Plumb. Plan Check 10.0 1 hrs $0.00 Elec. Plan Check lich. Pertnit Fee: Plumb. Permit Fee: IPPERMT Elec. Permit Fee: wl —ID-1— Olher.Wech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Insp Afech. Insp. Fee: Plumb. Irish. Fee: Elec, Insp. Fee.- — c!__ C_ :.--. C_­. NOTE. This estimate does not inctuaejees aue to orner"ePuriffwals jec. Klufftftms'. —.1 1 District, eta). These fees are based on the prelimina information available and are onjE an estimate Contact the Dept for addn 7 . info, FEE ITEMS (Fee Resolution 11-053 fff. 711112) FEE " 21772 COLUMBUS AVE DATE: 04115/2013 REVIEWED BY: MELISSA IlaADDRESS: r I # $10.001 BP#: *VALUATION: $1,000 Suppl. PC F . ee: iq Reg.' 0. OT APN: hrs $0.00 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration Repair PRIMARY SFD o r Duplex [ENTAM ATION 1 RPFIX P ERMIT TYP E: USE: $0.00 Suppl. Insp. Fee-0 Reg. 0 OT 0.0 hrs WORK REPLACE TUB & TILE IN HALL BATH SCOPE $0.00 Mech. Plan Check Plumb. Plan Check 10.0 1 hrs $0.00 Elec. Plan Check lich. Pertnit Fee: Plumb. Permit Fee: IPPERMT Elec. Permit Fee: wl —ID-1— Olher.Wech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Insp Afech. Insp. Fee: Plumb. Irish. Fee: Elec, Insp. Fee.- — c!__ C_ :.--. C_­. NOTE. This estimate does not inctuaejees aue to orner"ePuriffwals jec. Klufftftms'. —.1 1 District, eta). These fees are based on the prelimina information available and are onjE an estimate Contact the Dept for addn 7 . info, FEE ITEMS (Fee Resolution 11-053 fff. 711112) FEE MISC ITEMS Plan Check Fee: $0.00 r I # $10.001 Plumbing iBPF=RE Fixture set on One Trap Suppl. PC F . ee: iq Reg.' 0. OT 10.0-1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes (2) No $0.00 Suppl. Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 Phffi Permit Fee: $45.00 Consip-liction Tax: Administrative Fee: IADAffN $42.00 Work Without Permit? 0 Yes (2) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure 0 0 Travel Documentation Fee:. ITRAVDOC $45.00 Strong- Motion Fee: IBSEISAffCR $0.50 hrs $0.001 Inspections Inspection, Hourly Bldg Stds Commission Fee: 1BCBSC $1.00 M 11011 TA E 1. $143.50 - 15: $133.50 $10. 00 wt Revised: 04/01/2013 �gt.19�•r • j 2,g 9 l Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 Fax: 408- 777 -3333 CONTRACTOR I ,4I JP.00NTR A i-Tnu t IcT .JOB ADDRESS: ?/? z CoC�F�„ �,� , �� � PERMIT # _ OWNER'S NAME: f�'jc // L //v PHONE # Vie,'— -- Z GENERAL CONTRACTOR: BUSINESS LICENSE # CITY /ZIPCODE:/Z/i joC O 'Our iminirinni endo .,11 h....:.....,..... ,. _ Cement Finishing • -- �• • -•• =b ••• tilu --ity tu nave a �_Iry or t;upertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL, CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: Signature Please check applicable subcontractors and complete the following informatinn- Date ✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Paintino / Wallpaper Paving Plastering Plumbing Roofing Scptic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date