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14040021 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21350 COLUMBUS AVE CO TRACTOR:' /4- / A PERMIT NO: 14040021 OWNER'S NAME: SHEADE MARC R DATE ISSUED:04/02/2014 OWNER'S PHONE: 4082555276 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL REMODEL(E)HALL BATH(60 S.F.) License Class_ Lic.# Contractor4 z7/�h S a/y'Date=2-6 l'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 3700 of the Labor Code,for the orance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$7000 m 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:36205008.00 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 DAYS FROM 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 with all non-point source regulations per the pertino Municipal Code,Section 9 18. /� (/ RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtami ion, ee to remove all new materials for inspecti ❑ 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 ROO VERINGS BE ASS"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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 2553_ Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dater 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 IMCONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION fi 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 GUPERT[NQ (408)777-3228• FAX(408)777-3333•buildinga-cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS A 36 \ ,e, APN# n _ Q ^� OWNER NAME'w- Q�C_ o VK q 6 /�5�A-761 E-MAIL STREET ADDRESS d CITY,STATE,ZIP FAX CONTACT NAME C S PHONE IF Cv E-MAIL STREET ADDRESS O 4J CITY,$`I .T�QZFC� � r/8— FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR O CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT ,..r CONTRACTOR NAME r�- ` ; LICENSE NUMBER LICENSE TYPE BUS.LIC# G.i c13 COMPANY NAMEs/ '04 E-MAIL FAX � Y' �J Sly STREET ADDRESS E-7 p5-5 iry�y�0 r `�• CITY,STATE,ZIP s�Yi 611- 'Q /��C PHONE `Q/R k� ARCHITECT/ENGINEER NAME �'(''71 ➢LICENSE NUMBER �l Lf^ Cl/ / �J BUS.LIC#U V COMPANY NAME E-MAIL FAX STREET ADDRESS CITYY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE 1 #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLING UMTS: IS A SECOND UNIT []YES SECOND STORY OYES BEING ADDED? ONO ADDTTION?"' ONO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YESViax� .� AL VAL ATION: PLANNING APPL# [:]NO PLANNING APPROVAL LETTER EICHLER HOME? E]NO -1 M Its- By my signature below,I certify to each of the following: I am the pro er or authorized ageto ton the property o er's behalf. I have read this application and the information I have provided is correct. ead the Description of Work and ve�ntetr it is accurate. I ee to comply with all applicable local ordinances and state laws relating to building cons Ion. I authorize representatives of Cupertino toI the abo e tifie property for inspection purposes. Signature ofApplicant/Agent: e: 41. SUPPLEMENTAL INFORMATION REQUIRED �� Pc> YrE 3, olrilncsL3r _ New SFD or Multifamily dwellings: Apply for demolition permit for s 'tiOVER T.I-ICR M OTE F a Jaz ai , BUII.DII�G"P.LAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. EAPRESS PL NNIN PZ A vlEw 4� _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sT SnARn � _21d Woxxs "$w form if any Hazardous Materials are being used as part of this project. � � ���� � _Copy of Planning Approval Letter or Meeting with Planning prior to <� 4AYJORfsl I Ck SANTTPItYSEyVEKDI�TRICT submittal of Building Permit application. a i� k�.�ei`i`�*,� �'„ r,0�'EIVVIIi N114ENTAL'HEALTPI= ,�.. B1dgApp_201 Ldoc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21350 COLUMBUS AVE DATE: 04/02/2014 REVIEWED BY: MELISSA APN: 362 05 008 BP#: *VALUATION: $7,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY PENTAMATION 1 R3SFDREM USE: SFD or Duplex PERMIT TYPE: WORK REMODEL E HALL BATH 60 S.F. SCOPE yr u r M. ,-' �'-- ' L9<<;Ir. {'Carr C hick l'Tr�mh. t'Irirz C'heclz 11�>c..f �f;z C`t?cck ;L1 ';h. Permit Fee: l'letm#'. Permit it7rc r 1ta clr. lose 0(her Plumb Irup. C fhvr Itnp /,cc /'i iib, Fee: 1>tec lnr�, le< NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.£ Remodel,Bath(<=300 sf) Suppl. PC Fee: Reg. ® OT 0.0 hrs $0.00 $626.00 IREMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT 0,0 1 hrs $0.00 T_=_ PME Unit Fee: $0.00 PME Permit Fee: $0.00 C::"r.�rastl rrciIon TON Z,dministr ativc Fee: Work Without Permit? ® Yes E) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential E) Building or Structure 0 I7"tli''.t {.}OC:7177?E.'r'f9Ct17L?3'11`'(,'C?S': Strong Motion.Fee: 1BSEISMICR $0.70 Select an Administrative Item Bldg* Stds Commission..Fee: IBCBSC $1.00 $1.70 $626.00 !i7_117111",", TOTAL FEE: $627.70 , Revised: 04/01/2014 1v\)b s4 CufLp Ci EIS room (2-e m ocke APR 02 2014 'e4a pos'-'e C po(PIC pol T COM t ,yN`GDI f570N��n INO EN This set of s and cifi ations MUST be k pt at VI job site d' ring const uc i is unlawful to ake any changes or alterations on same,or to deviate #,,c-ofrom,without approval fficial. t r,nc HALL NOT O _ i r 1!tOr to e ain I O tFta viaiation . ;;, 3inance or State Law.