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13110115 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18890 PENDERGAST AVE CONTRACTOR:PAUL MILLER PERMIT NO: 13110115 CONSTRUCTION OWNER'S NAME: CHARLES SHAFFEER, 565 MACARTHUR AVE DATE ISSUED:11/18/2013 OWNER'S PHONE: 5302686462 SAN JOSE,CA 95128 PHONE NO:(408)219-4420 ❑ LICENSED CONTRACTOR'S DECLARATIO�N/ JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALE] License Class_ Lic.# , ' 7 i�3! 7 INSTALL(1)FIBERGLASS TUB WALLS ContractorThOL M I l _t cvQ0J(S Date 7-/7 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 37.00 of the Labor Code,for the performance of the work for which this permit is issued.. Sq.Ft Floor Area: Valuation:$750 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:37533043.01 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 C ED 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. Additionally,the applicant understands and will comply Date: /8 with all no - 'ntstmr a regulations per the Cupertino Municipal Code,Sectio 9 // RE-ROOFS: ure Date &Z3 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,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ageDate• f� 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 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 Off\ COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION \\ 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333•buildingCoDcupertino.org \ ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS �' ` APN# `? �—5 — -3 `, — D Lt OWNER NAME /--- PHONE c"�� E L7 STREET ADDRES �M, ! CITY,STATE,ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑ OWNER ❑ OwNER-BUII,DER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER 7FLI�CENS7ETYPE BUS.LIC# f COMPANY NAME E-MAIL FAX tLL STREET ADDRESS CITY,STATE ZIPPHONE S t� L /2 C 2 i`f ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK L a&S - A Lf S EXISTING USE PROPOSED USE CONSTR TYPE I #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODELAREA REMODELAREA PORCH AREA DECKAREA TOTAL DECK/PORCH AREA 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 - - UATIO z" w, PLANNING APPL# Fl NO PLANNING APPROVAL LETTER EICHLER HOME? �� a By my signature below,I certify to each of the following: I am the property owner or authorized agent 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 and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin construction. I ole entatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agen .. _ Date: SUPPLEMENTAL INFORMATION REQUIRED =,PLA7 CHEtrKT,,YP1 _New SFD or Multifamily dwellings: Apply for demolition permit for WENT `� B x D NGPLANREVIEW x existing building(s). Demolition permit is required prior to issuance of building3k § F permit for new building. Q EXPRESSO 3� � PLAlkI�TNGPLANRE1lEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARDx l kiIBiIC RKs form if any Hazardous Materials are being used as part of this project. LARGES �� FIRLDEPT �� Copy of Planning Approval Letter or Meeting with Planning prior to I1 JOR� C SANFfARY ER RDIST�tICT sub_mittal of Building Permit application. e x t ` N INN6NN'ENT4I I EAL'fi .r.: BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 18890 pendergast ave DATE: 11/18/2013 REVIEWED BY: melissa APN: 375 33 043' BP#: *VALUATION: $750 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPFIX USE: p PERMIT TYPE: A WORK install n fiberglass tub walls SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Fixture set on One Trap 1BPFIXTURE 1 # $10 TOTALS: T Ark U* $10.00 B i0ec:h. flan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Cheek F1,1ch.Perrin Fee: Plumb.Permit Fee: IPPERMIT Elec.. Permit Pee: CJlher Ale:cFs.Insh. LJ Other Plumb Insp. 0.0 hrs $47.00 Other fle(.Insp. Meeh.Insp. fee: Plumb. hal).Fee. Elec.Inst Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District;etc.). These -forees are based on the relimina in ormadon available and are onlyan estimate. Contact the Dept addn'Z info. FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fero: Suppl. PC I'ce PME Plan Check: $0.00 Permit Fee: supfel. Insp Fee PME Unit Fee: $10.00 PME Permit Fee: $47.00 Co nstruction ::.Ta : Administrative Fee: 1ADMIN $44.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fu,�S: Travel Documentation Feer 1TRATDOC $47.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 $149.50 $0.00 '` $149.50 Revised: 10/01/2013