09100012 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10292 BRET AVE CONTRACTOR:ELLEN HUDSON PERMIT NO:09100012
OWNER'S NAME: ELLEN HUDSON 10292 BRET AVE DATE ISSUED: 10/02/2009
'NER'S PHONE: 4084107750 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB F
License Class Lic.# MECH f- RESIDENTIAL r COMMERCIAL r
Contractor Date
JOB DESCRIPTION: REMODEL 40 SQ FT TO BATHROOM(E,P)
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions REPLACE SHOWER
Code and that my license is in full force and effect. NON-STRUCTURAL
1 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:$1700
1 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 APN Number:37510039.00 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 Issued bDate:
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.
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
Signature of Applicant: Date:
1 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
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)
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
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 1 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 CodeASccti 55A, 53Y3, nd 25534.Section 3700 of the Labor Code,for the performance of the work for which thispwner or authorized ageDate:G
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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. .lf,after making this certificate of exemption,I
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
1-on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
mnify and keep harmless the City of Cupertino against liabilities,judgments,
.,;s,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-poi source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. /
ate
Signature
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 37510039 . 00
DATE ISSUED. . . . . . . : 10/02/2009
RECEIPT #. . . . . . . . . BS000008818
REFERENCE ID # . . . : 09100012
SITE ADDRESS . . . . . : 10292 BRET AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER ELLEN HUDSON
ADDRESS 10292 BRET AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : GAIL JOHNSON
CONTRACTOR LIC # *OWNER*
COMPANY ELLEN HUDSON
ADDRESS 10292 BRET AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 700 . 00 1 . 00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 1, 700. 00 0 .50 0 . 00 0 . 50 0 . 00
1REMRESBAT SQ FEET 40 . 00 1140 . 00 0 . 00 1140 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 1141 .50 0 . 00 1141 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 1, 141 . 50 0682
---------------
TOTAL RECEIPT 1, 141 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
100 FOOTINGS 102 PIERS
104 REBAR 301 ROUGH PLUMBING
302 TUB & OR SHOWER 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 305 FRAME
307 INSULATION 308 SHEETROCK
309 EXTERIOR LATH 310 INTERIOR LATH
311 SCRATCH COAT 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erf ormed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side). - �•
Property Owner's Signature: . ,,i ate:
f
Job Address: 1 J- �E C Permit#
q3�o
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
JENT ALJE
F
'w f Af w Y h '
Assessor's Parcel Number:
Name of owner.
Project address. l 02-5 2- QP---SA 8
Contact person. Phone. -A-116 ' -7 7S0
Fax.
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor: /
Garage:
TOTAL: -
Are there at least two 10 foot by 20 foot clear spaces inside the garage?
is privacy protection planting required for the project? .---Y N
On what floor(s) is work being done? r'
Brief description of work. 4661-#/1•eaA-te c,� i",,9/1 ,5�2t,(e-7-C4O-AL-
Code editions:2008 CBC (V-N)2008 CFC -N)2008 CMC ( -N)
2008 CPC (Y -N)2008 NEC -N)
APPRt wE0
Effective 1/1/08 IN ACCORDAN('I WITH THE CITY OF
CUPE_RTINO CODES AND ORDINANCES
DATE___
SIGNED
This set of plans and spec
ficaUons MUST
be kept on the lob at all times and it is
unlawful to make any changes or alterations
on same without written permission from
the Building Departn'ent. City of Cupertino.
The stamping o thjs plan and specifications
SHALL NOT be hel•t tc,i )" or r o iso s
approval of the wnl,+ti .n„f aryl e Law.
of any City Or�1�� .���C.e�,�r
Plan Review Process Work Book Page-8-Revised 1/1/08
t'
O R
16
rt
C% a
t
z
� p
n
GO
`_� ✓l si-r
1
CITY OF CUPERTINO
ADDITION/REMODEL
CUPEkTINO PERMIT APPLICATION FORM
C� I bbv 12
APN # Date:
Is a 2" unit being added? Yes ❑ No If yes, please fill out the permit application for 2" unit.
Building Address:
!oma Z2' ,�.� � 1���lJ7Z
Mailing Address (if different from building address):
Owner's Name: Phone# : i1_1 o , 7 7 v
Contractor- Phone#: �41
`tj !L t�� f� c�/✓- ��/ �.L �l �� Fax #:
Contractor License#:
Cupertino Business License#:
Contact: Phone#: �g L//I� 7 75-D
D
L J 41g�5o/V Fax #:
Building Permit Info:
Bldg. ® �� Elect. �� Plumb. []-� Mech. ❑ Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including addition)?
Remodel Includes Re-Roof Yes ❑ No If es list n�r of s uares
Y q
Remodel Includes Structural: Yes ❑ No
Do you have the pre-application planning approval? Yes ❑ No ❑
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B ®�
Valuation: / �1.� Please check this box if the project is a
second-story addition ElProject Size: Express and ❑ Large ❑ Ma'or❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set& the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 07/06/09
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
DECKS 1R3SFDADD OR
1R3SFDREM
1 DECKWOOD Deck (Wood)-Each B
(Each)
1 DECKRAIL Deck Railing-Each B
(Each)
GARAGES 1R3SFDADD OR
DETACHED 1R3SFDREM
1GARDTW<=1K Wood Frame up to B
1,000 SF (each)
1GARDTM<=1K Masonry up to 1,000 SF B
(each)
1 BCONSTAXR Construction Tax Res
(new detached garage)
PATIO'S OPEN 1R3SFDADD OR
1R3SFDREM
1 PATIOWOOD Wood Frame up to 300 B
SF
1PATIOMETAL Metal Frame up to 300 B
SF
1 PATIOOTHER Other Frame up to 300 SF B
PATIO'S CLOSED 1R3SFDADD OR
& SUN ROOMS 1R3SFDREM
1 PATIOENCLW Enclosed Wood up to 300 B
SF
1 PATIOENCLM Enclosed Metal up to 300 B
SF
1 PATIOENCLO Other Enclosed Patio up B
to 300 SF
1 COVPORCH Porch Covered-Each B
(Each)
REMODELS 1R3SFDREM
1 REMRESKIT Kitchen Remodel up to B (Deduct "$"for ea plan
300 SF check
1REMRESBAT Bath Remodel up to 300 B 66
SF
1REMREOTH Other Remodel up to 300 B
SF
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1MECPLNCK Stand Alone Mechanical M
Pln Ck (hourly
1PLMPLNCK Stand Alone Plumbing P
Pln Ck(hourly)
j 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
/ Commission Fee
/ 1BSEISMICRE Seismic Residential B
1TRAVDOC Travel &Documentation B
1BUSLIC Business License B