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13070095 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22821 MEDINA IN CONTRACTOR:INNOVATIVE TILE PERMIT NO:13070095 CONCEPTS,INC. OWNER'S NAME: PONCE ROBERT A AND SCOTT-PONCE 765B MCGLINCEY LN DATE ISSUED:07/15/2013 OWNER'S PHONE: 4089962046 CAMPBELL,CA 95008 PHONE NO:(408)371-8858 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALEI License Class C` 4Lic.#sS 63 O APT.A&B- A-REMODEL BATHROOM 103 SQ FT, B-REMODEL(2)BATHROOMS 98 SQ FT Contractorf/1//l/L�lr�ll��G. ate ��3�?zf3 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. Sq.Ft Floor Area: Valuation:$20000 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:34230011.00 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 80 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 DA F OM 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 by: Date: granting of this permit. Additionally,the applicant understands and will comply / ,•l with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. e//i�� r RE-ROOFS: SignaturDate 13 Zv/3 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: 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. 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,Sectiones-255055,,25533,and 25534. Section 3700 of the Labor Code,for the performanceof the work for which this Owner or authorized agent::OG (vim/ � Date: P3 pty 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 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 upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECTS DECLARATION 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 IA CONSTRUCTION PERMIT APPLICATION �D COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION '10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERTthCO (408)777-3228-FAX(408)777-3333-building a�cupertino.org 0 ❑NEW CONSTRUCTION ❑ ADDITION ❑ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS Z2*Z/ 'Afe w"A' G 1APN` 3412 3 V D 1 1 I SD S CITY,STATE,ZIP FAX Z Iq D I N A 1-4-PJ C C� 4"7^Vo e h 9SO1 CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX OWNER ❑ O)XNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT v❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME �� LICEN Q LICF�ISE BUS.LIC# OvAnyleL !/ 7//7 l G /K! LA�.7 G✓ •Ng9'COMPANY NAME 1A FIjW .9 Ax /-39J6 � !WDS C STA PHONE 64/AJ C4 G4-V467 71 92" ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK it- 7-Ile- `N 7-&,9 � - (s) *WQ fZLEA .3 13 Aavots p1 EXISTING USE PROPOSED USE CONSTR TYPE I I STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA 3Z)( AREA AREA 3Z (/ NET AREA 3 Z BATHROOM KITCHEN OTHER REMODEL AREA 32 REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA EIDETACH ❑ATTACH 9 DWELLINGUNrrS: IS A SECOND UNIT []YES SECOND STORY ❑YES BEING ADDED? ONO ADDITION? ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN []','ES =1L£CIrI -1' -�-' ,+``"'- :-CiQ TOTAL VALUATIOA- PLANNING ADPL n ❑NO PLANNING APPROVAL LETTER EICHLER HOME? []NO 'S-_ - - - / .y (]"O By my signature below,I certify to each of the following: I am the property owner or authorized Writ to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work anZI verify it is accurate. I agree to comply with all applicable local ordinances and state lavas relating to building consUpction. I auth rize representatives of Cupertino to enter the above-identified property for inspection purposes., SiSnatureofApplicant/Aeent: Date: 711 S/U/ SUPPLEMENTAL INFORMATION RE � � t Q _New SFD or Multifamily dwellings: Apply for demolition permit for N � :�. �- r r �� • existing building(s). Demolition permit is required prior to issuance of building THE c » BIInL�cxL permit for new building. � � #AXP S -= � PLAI.'I��II.O PLAnI2Ev3Ew� `: _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure T� - k �� O P � � �� : form if any Hazardous Materials are being used as part of this project. �P RG _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. I+ olz LsArrr . YSE�i�R�7STitIC'f BldgApp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22821 medina In DATE: 07/15/2013 REVIEWED BY: Mendez iQ1APN: BP#: *VALUATION: 1$20,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY PENTAMATION SFD or Duplex 1 R3SFDREM USE: PERMIT TYPE: WORK Apt.A& B- A- remodel bathroom 103 sq ft B- remodel 2 bathrooms 98 sq ft SCOPE RNMME n INE .n r-0 �° NOW- Xtec:h.Plan Check Plumb.Plan Check Elec.Plan Check ;Ltecb-Permit*"ee.: Plumb.Permit Tee: Elec.Permit Fee: 7 Other Mech.Rup. Other Plumb Insp. Other Elec.Insp. Li 1lech.Insp. Fee: Plumb. Insp.Fee: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These ees are based on the preffinWina information available and are only an estimate. Contact the De t or addn7 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 sfl Suppl.PC Fee: (D Reg. .® OT 0.0 hrs $0.00 oe 0 1REMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Feer Reg. 0 OT0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction TCM, T_r Administrative hee: 0 Work Without Permit? ®Yes 0 No $0.00 E) Advanced Planning Fee: $0.00 Select a Non-Residential 0 Travel Documentation Fees: Building or Structure Strom Motion Fee: IBSEISMICR $2.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 0' $3.00 6.00 ` N _ 9.00 Revised: 07/01/2013 e1-t P0/'j C e ( puFLr,-x, v r i4s A 2 2-9;Z I /I&-v i,v A- ° °' �' f, k 2 LC r i3 z '� � P 3 Lin 0 30 11 Wh -7016 I 0 W •3 - i l Umi �- ` U i 1 COMMUNITY DEVELO ARTMENT -W$ 7 Z) BUILDING DMSI APPRONW G This sd of plans and specifications MUST be kept at the 19 81A job site during construction. It is unlawful to make any changes or alterations on same, or to deviate therefrom,without approval from the Building Official. The Stamping of this plan and specifications SHALL NOT be held to permit or to be an approval of the violation =04 of any provisions of any City Ordinance or State Law. °m i gY �\A� . ,�_ .15 I3 !5T7 N QATE R(tAIT NO, d �SN 4b CJ Fri L `r. PT1-1-4��c- 'n4 i / Cllr t Ni UArry i i 1C, s Building Department City Of Cupertino 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 =