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13100183?I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10792 BROOKWELL DR CONTRACTOR: FISCHER PLUMBING & PERMIT NO: 13100183 CONSTRUCTION OWNER'S NAME: DAVIS PAUL H AND BARBARA D 2766 SCOTT BLVD DATE ISSUED: 10/28/2013 OWNER'S PHONE: 4082538015 SANTA CLARA, CA 95050 PHONE NO: (408)727-2426 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL CI License Class 23 Lic. # — REMODEL MASTER BATH 38 SQFT- ENCLOSE MASTER CLOSET Contract Date L' 3 TO ENLARGE MASTER SHOWER I hereby a rm th t I am licensed under the provisions 4f Cha ter 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 Sq. Ft Floor Area: Valuation: $12000 performance of the work for which this permit is issued. 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: 36921034.00 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 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 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 'onally, Issued by: Date: granting of this permit. Add' the applicant understands and will comply with all non -point s cc lations per the Cupertino Municipal Code, Section 9.18. „ J�7 Z Signature Date� 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. ❑ 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) 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. 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 Cup rtino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sec'PS 05, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized age Date: 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 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building()cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS \ , J APN # 2' — G 03 �J 1 / U OWNER NAME PHONE E-MAIL STREET ADDRESS C/ITY, STATE, IP _ '/7] FAX . L� I r,O - n /� / � 1� 6 CONTACT NAME If PHONE E-MAIL STREET ADDRESS .o - CITY, STATE ZIP _ �� C��r� FAX ix? s R, ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT,. CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMEi �• �a LICENSE NUMBER LICENS TYPE BUS. LIC # t i d— COMPANY NAME E-MAIL FAX ESS J CIT, STAT ZIP CS � P ONE LU F, ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF ORK .. �Pb±1 4 X%�`>�/ za EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA,3p 0 REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEI ED Y: TOTAL VALUATION PLANNING APPL # []NO PLANNING APPROVAL LETTER EICHLER HOME? [:]NO 1 By my signature below, I certify to each of the following: I am the property owner or authoriz d ag ct on the property owner's behalf. I have read this correct. I have read the Description of Work and rify it is accurate. I agree to comply with all applicable local application and the infor��F7) ordinances and state lawsnstruction. 1 authorize representatives of Cupertin to enter the above-identifie roperty for inspection purposes. Signature of Applicant/A n Date: /O 2-� SUPPLEMENTAL INFORMATION REQUIREDP cxEcx YPE ROUTLIP OVER-THE-COUNTER UILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of buildin permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ 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 El MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ' ENVIRONMENTAL HEALTH BldgApp_201 Ldoc revised 06/21/11 I) CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ejf 711113) ADDRESS: 10792 BROOKWELL DR DATE: 10/28/2013 REVIEWED BY: MENDEZ �hteh. t'c>rnrrt Flcc' APN: BP#: "VALUATION: 1$12,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: o, Phtrl_ Ii'h. Ica PENTAMATION 1 R3SFDREM PERMIT TYPE: WORK I REMODEL MASTER BATH 38 SQ FT CONVERT CLOSET SPACE TO LARGER SHOWER SCOPE NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ejf 711113) Lfc�c:h. 1'?arr t `heck �hteh. t'c>rnrrt Flcc' Phtmh. Pexm';t Fcc: 1"Y' t' Permit F"', <hh'r ;lleah =s.£ $626.00 E1__L_ 1'ltx{�. Imp. o, Phtrl_ Ii'h. Ica I'ze, NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ejf 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 =s.£ $626.00 Remodel, Bath (<=300 sf) IREMRESBAT Suppl. PC Fee: Q Reg. Q OT 0,0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -.0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 �,OF1Sl7'11CttOn x(7.1': Adinhiistrative lee: 0 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 11-avel 00cl nc tito(ion Dees: Strong Motion Fee: IBSEISMICR $1.20 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $2.20 $626.00 TOTAL FEE:' $628.20 Revised: 10/01/2013 z��ilc+�r �a1c,.oe� Unlvc.'_ -taf�e �ir� Cq{Pt�(�l✓N S eAsor 4. Ct►�.5� iw �'�r". C�rr�ic�irrr' RCt��S 4-o •�r v � � � !>� �''` :;-fin t � 1.%�i �iacn 6')"���l,�,c. t � � <.d (t� r•,v� I�atk( Ja0�s tv-30T2 or,"'okwecf 6r - %u f"rl to u C -A • (i $ © IV ( c�n55� ) �2- s 3 1301 C, 0 3 iu aE.CD5. yC N - N N O LLJ >hi C •y A C d fl O N /0 O co y U p `> U - -o f0 C Q y Q N O (9 1-1 L O d ♦... l0 IOctO N ,.. rn v O C O O Q�` N X-:. f.7 I�atk( Ja0�s tv-30T2 or,"'okwecf 6r - %u f"rl to u C -A • (i $ © IV ( c�n55� ) �2- s 3 1301 LO m!,n A m -466 co — 04 ce) I- OD I -q C'4 00 0 A w w 0 w w U- Ir.9 . ....... ... v4l� CUPERTINO -linq DePartment REVIEVv�C,t,:Lj- IANCE- COi'AR- Reviewed