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14060108 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10240 RANDY LN CONTRACTOR:AP AMERICAN PERMIT NO: 14060108 CONSTRUCTION OWNER'S NAME: BURSTEIN LOUBA 5632 VAN NUYS BLVD STE 367 DATE ISSUED:06/17/2014 OWNER'S PHONE: 4083680234 VAN NUYS,CA 91401 PHONE NO:(818)301-5354 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑ BATHROOM REMODEL LIKE FOR LIKE 50 SQ FT. SEE License Clas n � LiLc.# T 1 2"' HANDOUT Contractor AP ro 66h ,ham y Date I I l/ I hereby affir�t 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:$10300 cty 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:31623094 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 D 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 FRO LAST LLED INSPECTION. indemnify and keep harmless the City of Cupertino again ilities,judgments, costs,and expenses which may accrue against sai . consequence of the ./ granting of this permit. Additionally,thea nderstands and will comply Issued by: Date: with all non-point source regulations upertino Municipal Code,Section 9 18. 0/ 1 RE-ROOFS: 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 1,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 Cupertino Mu ' Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505, 3,a 5534. �^ Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: (} 7/1' 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 �v COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408) 777-3228• FAX(408)777-3333•buildingaCkupertino.orq \ CUPERTINO ❑NEW CONSTRUCTION El ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT 4 PROJECT ADDRESS , r / / �/� APN# 3�� y3 6 q y OWNERNAME (� L // P ONE E-MAIL STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CO ACTO AME I LICENSE NUMBER LICENSE TYPE BUS.LI '^ COMPANY NAME koV A�� - E-MAIL FAX STREET ADDRESS �JI'�V CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK 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 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 U '17 1 PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES OyRECEIVEDBY t ", TOTAL VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO '"��' t _� O By my signature below,I certify to each of the following: erty owner or authorized agent o act property owner's behalf. I have read this application and the information I have provided is c t. I read the Description of Work and verify it accurate. I agree to comply with all applicable local ordinances and state laws relating to buil I authorize representatives of Cupertino to enter the above-i entifiie pro rty for inspection purposes. Signature ofApplicant/Ag Date: SUPPLEMENTAL INFORMATION REQUIRED , } pAx CHECKTYPE xouTmc:'sLIP, New SFD or Multifamily dwellings: Apply for demolition permit.for o'ExTHEcouI�TERuuDII;cPLeNxE�IEw N existing building(s). Demolition permit is required prior to issuance of bulldingrt permit for new building. © E?.PRESS ©t PLANAING PLAN REVIEW f V. w _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure y❑ sTannTin PIIBLIawoxKs form if any Hazardous Materials are being used as part of this project. � '` ❑ PniE DEPT h _Copy of Planning Approval Letter or Meeting with Planning prior to QjpR�+' �"I,BAI�ITr1RX SExi'ER DISTRICT submittal of Building Permit application. e.s. BldgApp_201 Ldoc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS:/ 1A DATE: 06/17/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$10,300 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM USE: p PERMIT TYPE: WORK bathroom remodel like for like 50 sq ft. see handout SCOPE Phlolh. Plan C rxzt ,L7 M"3.raid Fee: Plumb, f r nw Lie(, Per r'1""e lee's:, base'= f)YIRer 111u rth 7rrsr7- (?il.e>'t zt�`c.I��sl;. Llcc'z. Li hr sp_ Pe"': P1790. hisp. Veer: If sp NOTE:This estimate does not includefees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These _f -fees are based on the relimina information available and are onlyan estimate. Contact the Detor addn'1 info. FEE ITEMS(Fee Resolution 11-053 Ef. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.f. 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 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Co r,;ra'trc't r of Tax: r Lld'6i2321,4 tt'G7r1 b`c?d`'i,,c: 0 Work Without Permit? ® Yes (j) No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure 0 .1>`itl`s'l .}tlf'ftdi'lt'rtftdl7fl7't Fees: � Stront.T Motion Fee: IBSEISMICR $1.03 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $2.03 $626.00[ TOTAL FEE: $628.03 Revised: 04/01/2014