13090222 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22436 RANCHO DEEP CLIFF DR CONTRACTOR:KITCHENS BY MEYER PERMIT NO:13090222
OWNER'S NAME: RITA FINN 278 CASTRO ST DATE ISSUED:09/30/2013
OWNER'S PHONE: 4082573396 MOUNTAIN VIEW,CA 94040 PHONE NO:(415)968-8318
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.k
2—,--�> RETILE M.SUITE TO INCLUDE REPLAC SHOWER STALL,
NEW
ContractorI k e tte d �j TILE PLUBMING FIXTURES
I hereby affirm that I am licensed 4der the provisions of hapter
(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
ompensation,as provided for by Section 3700 of the Labor Code,for the
i
onnance ofthe work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5000
ve and will maintain Worker's Compensation Insurance,as provided for by
ion 3700 of the Labor Code,for the performance of the work for which this APN Number:35602053.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 0 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 M LAST CALLED INSPE TION.
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.. ss permit. Add' ' applicant understands'and will comply
withalnon-point soyree ni �o er the Cupertino Municipal Code,Section
9.18. � s
�i� RE-ROOFS:
F'/•
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:
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 Area.F-J,
lity Management District I
performance of the work for which this permit is issued will maintain compliance with the CupertinoalCode,Chapter 9.12 and
p the Health&Safety Code Sec255 , 25534I have and will maintain Worker's Compensation Insurance,as provided for by j
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent-
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. If,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
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 2
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION p(L2
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 3�"1
CUPERTINO (408)777-3228•FAX(408)777-3333•building(Q-cupertino.org \ V
❑NEW CONSTRUCTION "�❑ ADDITION ❑ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRES! h/�� ISI n rL4V! n y��{h I `APN 2 5) e 0,2-d53. a
OWNER NAME �ArA ��,(��[(/ (J PHONN* Jy p_�N10 I E-MAIL
ST$�,LAD S TY S TE, 4- FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUHAER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENS R LICE TYPE BUS.LIC#
C AME I�\(,o ({l
STREET S 61
Cptnr^,O Nly
kaaL, ffil,STAT$, P I 'O O P ` n S�
ARCHITECT/ENGINEER NAME 1 LICENSE NUMBER (�' BUS.LIC#!�
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK ko o e "--2 -j V e
i A.> Ci ( ^46 OQ -SIV-5
PrP
EXISTING USE PROPOSED USE CONSTR TYPE 1 #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM I KITCHEN - OTHER
REMODELAREA REMODELAREA REMODELAREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY []YES
BEINGADDED? []NO ADDITION? []NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES
PLANNAIG APPL# []NO PLANNING APPROVAL LEITER EICHLER HOME? ❑NO c-st3 .; P,
75
By my signature below,I certify to each of the following: I am the perty owner or authorLJed aVKt to act on the property owner's behalf. I have read this
application and the information I have provi ct I h ea d th cription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws b 'ting to g construc' .u entatives of Cupertino to enter the above-id 'fled proppyfor inspection purposes.
Signature of Apphcant/Agent: Date: 012013
SUPPLEM AL INFO TION REQUIKED ei Arr C trE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for r
existing building(s). Demolition permit is required prior to issuance of buil g 43 OVER`-THE COUNTER Y ❑ BUILDING PLAN REVIEW
permit for new building. E7FPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure O sTANDAItb L, ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
4[] LARGE, �: ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MA?oR ❑ SANrrARY'sEwERDISTRICT
µ`I..:. ❑ ENVIRONMENTALHEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 22436 rancho deep cliff dr DATE: 09/30/2013 REVIEWED BY: MENDEZ
APN: I BP#: *VALUATION: 1$5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Du lex PENTAMATION 1RPFIX
USE: p PERMIT TYPE:
WORK re-tile m.bath new fixrtures
SCOPE
L1ech.Plan Check� Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan t7heck
iV1e111. Permit Fee: Plumb.Permit Fee: IPPERMIT IT;lec.Permit l'ee:
Other Alech.Insp. Other Plumb Insp. 0.0 �rs $47.00 Oalter Elec.Insp, ED
Allech.Insp. Fec: Plumb. Ins11.Fee: Elec,Insp.lee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These Pes are based on the prelimina information available and are onl an estimate. Contact the Dept for addn 11 info.
FEE ITEMS (Fee Resolution 11-053 E . 7ff 11113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Supp/.PC Fee: Reg. 0 OT Fo.0 hrs $0.00 $10.00 IBPFIXTURE Fixture or Trap
PME Plan Check: $0.00
Permit Fee: Hourly Only? Yes Q No $0.00
Suppl. Insp.Fee-.0 Reg. 0 OT 0;0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
C'onswuction :Tax:
Administrative Fee: IADAffN $44.00
Work Without Permit? 0 Yes O.No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential G
Travel Documentation Fee: 1TRAVDOC $47.00 Building or Structure ®�
Strom Motion Fee: IBSEISMICR $0.50 F1.0 hr. Inspections
Bldg:Stds Commission Fee: 1BCBSC $1.00 $139.00 ISTINSP Inspection,Hourly
$139.50 $149.00 _ $288.50
Revised: 08/01/2013