13060054 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10767 BROOKWELL DR CONTRACTOR:GREEN ENGINEERED PERMIT NO: 13060054
STONE
OWNER'S NAME: HENRY&MAUREEN PAVY 551 LARNEGIE DATE ISSUED:06/07/2013
OWNER'S PHONE: 40844697]0 MANTECA,CA 95337 PHONE NO:(209)249-8628
A- LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALU
LicenseC Lic.# 95'T 232 REMODEL(E)BATHROOM,NO STRUCTURAL CHANGES
Contractor Date l—�
I hereby aftir ra I am licensed under the provisions of Chapter 9
(commen ' ith ection 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. Sq.Ft Floor Area: Valuation:$10000
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 APN Number:36921011.00 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 DAY ALLED 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. Ad itionally,the applicant understands and will comply Iss b : Date:
6/-Z
with all non-point sourpe r lations per the Cupertino Municipal Code,Section
9.18.
6-? /� any
Signature Date G All roofs shall be inspected prior to any roofing material being installed:If a roof is
Jr installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I 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)
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. 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 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 Ar Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cu rt, o Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Co �ono3,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ageDate:L,7—/
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 CONS RUCTION 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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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
CONSTRUCTION PERMIT APPLICATION 0
b�
is COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 O
CUPERTINO (408)777-3228-FAX(408)777-3333-building(ftuaertino.org 1�
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT/07/
DRESS ,IRp � ` APN# 3 2- 1a7 IR4ok"Amil Pr
OWNER NAME r t?V D /Y) Y� PHONE ,I `/��jD E-MAIL
STREET D SS 8� ` STATE, - FAX
CO ACT NAME M9-641-7—
HONE -641/ 310-31 E-MAILE-MA
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT XCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CQ(VTRACTORft � LICSE NUM'E LICENSE T E BUS.LIC# 337
99
COMPANY N E7�E 6 FAX
GrtoeyL Gina n I . 60�r /fir e f e4pm
STREET RE �` 7� C TA �K PHS,-aY a
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME I-- FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OFWORKw
EXISTING USE PROPOSID USE CONSTR TYPE #STORIES
�>�var�e I USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL f
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT OYES SECOND STORY ❑YEs
BEING ADDED? ONO ADDITION? ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN RECE OTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO
By my signature below,I certify to each of the foll ing: I am the property o or authorized n the property owner's !f. I have read this
application and the information I have provi i correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state law a atin to co sttuction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: 12 Date:
SUPPLEMENT ON REQUIRED pLK TYPE ROlrrnvs sL>p
_New SFD or Multifamil w Ings: Apply for demolition permit for ❑ OVER-T> COUNTER ❑ BUILDING PLAN avlEw
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ FmREss ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
form if any Hazrious Materials are being used as part of this project. p LARGE ❑ FmE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MMOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONWIffAI HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10767 BROOKWELL DR DATE: 06/07/2013 REVIEWED BY: MELISSA
APN: 369 21 011 BP#: "VALUATION: 1$10,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDRE
USE: PERMIT TYPE:
WORK REMODEL E BATHROOM NO STRUCTURAL CHANGES
SCOPE
vg
XI
IN
s _
:Wch. Flan Check Phimb.Plan Check Elec. Plan(,,heck
h�1ec%.Permit Fee: Plumb.Permit Fee: Elec. Permit Fee:
Other Afech.Insp. Other Plumb Insp. EIF Other Elec.Insp. ET
1lech.Insp,Fee: Plumb. Insp.Fee: /Ekm.Insp.Fre:
NOTE.This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the relimina information available and are onlyan estimate. Contact the Det or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = s.f. Remodel,Bath(<=300 sf)
Suppl. PC Fee: 0 Reg. ® OT 0.0 hrs $0.00 $600.00 1REMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Feer Reg. ® OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
construction Tax: F71
Administrative Fee:
Work Without Permit? ®Yes 0 No $0.00 E)
Advanced Planning Fee. $0.00 Select a Non-Residential E)
Travel Documentation Fees: Building or Structure
i
Strong Motion Fee: IBSEISAffCR $1.00 Select an Administrative Item
Bldp,Stds Commission Fee: IBCBSC $1.00
gRmw
2.00 600.00 O i
$ $ $602.00
�• Revised: 04/29/2013
Building Department
City Of Cupertino
LM 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST.
JOB ADDRESS: /6-7467PERMIT# O�,00
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR:;v-Lce" 5 . 'BUSINESS I;ICENSE,# ,3 37
ADDRESS:.,9�jJ L C ?-ems CITY/ZIPCODE
*Our municipal code re uires all businesses working in the city to have a City.of Cupertino business license..
NO BUILDING FINAL OR FINAL OC#ndcomplete
INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR ACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: _ —`
gnature Date
Please check applicable subcontra rs the following information
j/ SUBCONTRACTOR BUSINESS NAME .,,,-,BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
HeatingA 1'e7
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
LAYOUT SHEET
(�V $1�r�reee �pV1 Templator: Date: G Page: ov
4 ,s mwys�uszzgtomer Name: l9y q
Phone ! z4fg)2� S ldress: 076 n®C9kLe��L/
Phone City, ST Zip:
Fax:
Ccs `l9 j.��-t6 fflgGJC--Top Edge:
anq—GO7-343) Splash Edge: 1cm 3cm Full Height: Y N
Model: UM TM In Shop: Sink Sink Template
Faucet Holes: Outlet cutouts: Faucet: In Sink In FT/�op l
I accept the countertop layout and dimensions, including seam locations. E'�« 1,� r P`ni
Customer Signature
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Elegant Surfaces 551 Carnegie et, Manteca, A 95�3?°;�(�0w 23=9322
460 Harter Avenue, WOOdlan CA 95776, (53'0')'S68-9790
Updated April,2004