15010068 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10410 MILLER AVE CONTRACTOR:TREEIUM INC PERMIT NO: 15010068
OWNER'S NAME: LEE SHAW W AND KATHRYN J 433 HEGENGERGER RD STE 108 DATE ISSUED:01/12/2015
OWNER'S PHONE: 4088071232 OAKLAND,CA 94621 PHONE NO:(510)300-1922
go LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL E]
�( KITCHEN REMODEL 112 SQ FT TO INCLUDE M,E,P'S
License Classn n L�ic.#
Contractor �( '(�j[ Date ^
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$16000
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:37505042.00 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 WIT�IIN 1 IT 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 ISO DAYS F OM LAST LLED 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 Issued by: Date:
with all non-point source regulations per the Cupertino 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 obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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 /�J
Owner or authorized agent: U ,(' —42 Date:
permit is issued. I
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
918.
Signature Date
CONSTRUCTION PERMIT APPLICATION DO
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION to
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 r�
CUPERTINO (408)777-3228• FAX(408)777-3333•buildingCa?cugertino.or_q
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 1® O h. .1 l/Py pv n c / ,I PA 1 tAPN# ^ Ca ,
OWNERNAME - '/'C (� PH�O`NEf n^ E-MAIL y
STREETADDRESS '�f��
V' CITY, STATE,ZIP 1� p , _ FAX
CONTACT NAME `1 ` • PHONE E-MAIL
a
STREET ADDRESS CITY,STATE,ZIP FF
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAM h t` LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME7 E-MAIL FAX
STREET ADDRESS i. - I -CITY,STATE,ZIP�'/� 1 r� G PHONE
ARCHITECT/ENGINEER NAME 1n LICENSE NUMBER V v �JI/' „J) BUS.LIC#
COMPANY NAME E-MAIL t "y 1 FAX
STREET ADDRESS r CITY,STATE,ZIP PHONE
DESCRIPTION OF WORKbb-
EXISTING USE PROPO�ED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA' AREA NEIAREA
BATHROOM KITCHENyg OTHER
REMODEL AREA REMODEL AREA!1 REMODEL AREA
PORCH AREA DECK AREA TOTAL DEcIK/PORCH AREA I GARAGE AREA: DETACH
[]ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY []YES
BEING ADDED? ONO ADDITION? []NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES t.RE EiYEDt-'Y -. id TOTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO ? �,� p.
�..� 6 0,lI9
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on t operty owner's behalf. I hav 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 relating to buildin c n traction. I authorize representatives of Cupertino to enter the abov -identified property for inspection purposes.
Signature of Applicant/Agent: Date: 1�`s
SUPPLEMENTAL INFORMATION REQUIRED rcicKa'rr e r h `,1,JovTilvc
N 'SY.?l ail"k > `+'
New SFD or Multifamily dwellings: Apply for demolition permit for a
R'THE-COUNTER ❑�$UJSDINGPLANREVIEW
existing building(s). Demolition permit is required prior to issuance of buildm �s
p l
permit for new building. EXr ss ,� ��LANNINCPL�vxEvw
�a"i 4a fi '`.. R t
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure � SAI 1)Ai2D v � UBLIcwOR"
form if any Hazardous Materials are being used as part of this project.
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. �® J ' '� " � I CnR EwERnlsTxicx
ONMEN'I'ALHEALTHe x.
BldgApp_201 Ldoe revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10410 miller ave DATE: 01/12/2015 REVIEWED BY: Mendez
APN: BP#: "VALUATION: 1$16,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 R3SFDRE
WORK kitchen remodel 112 sq ft to include m e 's
SCOPE
NOW _
l; crt 7 `a,r C:?terk llhtfnb7 Plum Chem
14ccat. P,,emit fee Ph,mn. Permit Pian: El':" Ax(-/,cc:
(1;her;i1r c:bt Irr.�;>. Ofhwr-Plumb Insp. of ter•Elcc:.ItFslz.
LL��]
W cb frzsv.L,:e: I'Iursh. Irt.p. Fee: J-17c(.Imp Ise:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees 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 E . 7/1/13) FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 = s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: Q Reg. 0 OT 0.0 1 hrs $0.00 $645.00 IREMRESKIT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.(F) Reg. ® OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
£:coast iwtion Tax:
�'Jd;ninisirat4v Fee:
Work Without Permit? ® Yes (F) No $0.00 1 1 E)
Advanced Planning Fee: $0.00 Select a Non-Residential E)
r�,.Ivel Doct.un cntration/Fees: Building or Structure 0
i
Strong Motion Fee: IBSEISMICR $2.08 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$3.081 $645.00 .—. sAL FEE:
Revised: 01/06/2015
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
W*PERMIT
DDRESS: 10410 miller ave DATE: 01/12/2015 REVIEWED BY: Mendez
PN: BP#: *VALUATION: $16,000
PE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY
SFD or Duplex PENTAMATION 1 R3SFDRE
USE: PERMIT TYPE:
WORK I kitchen remodel 112 sq ft
SCOPE
-------------
i VIVO
Af dl: 1:1o.I C'ae:rr' 1'I'irttr .I'lcurr C."kre;cl 1_r'er.1' C`,'a°c rt
1c>cr`7_ T'c. r1'1 Fee: I'Ir,mb. 1'ermit Fee:
ot1wv Heck,Ir;sp, C 1her 11I117rtb Irisp. Ll L_ Other h.&(.Ir,vp. Ll
ELL��]
1"locil ?P_<zz �e: Phaitlz hjrvp. Fee: I"lec'..ns") t�°:C'
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etG). These ees 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 Ef 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 =1 s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 $645.00 1REMRESKIT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.(j) Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: _F_T $0.00
C.'onstr°rrNion Tax:
Work Without Permit? ® Yes (j) No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential G
Travel Docr.rrrlenualion 1''cees. Building or Structure 0
i
Strong Motion.Fee: 1BSEISMICR $2.08 Select an Administrative Item
Bids Stds Commission Fee: IBCBSC $1.00
a`Ur
$3.08 $645.00 = TOTAL FEE:= $648.08
z Po
Revised: 01/06/2015
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REVIEWED FC7�DUDE COMPLIANCE-
ED
Reviewed By: _.
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