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14120101 CITY OF CUPERTINO BUILDING PERMIT 4?p BUILDING ADDRESS: 10440 MANN DR CONTRACTOR: /-- PERMIT NO: 14120101 OWNER'S NAME: PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL © �y REMODEL(E)MASTER BATH(63 S.F.) License Classp_ Lie.# —f o i5 Contractor f J vW Date I hereby affirm that I am licei sed 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 erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$11394 ave and will maintain Worker's Compensation Insurance,as provided for by ection 3700 of the Labor Code,for the performance of the work for which this APN Number:32645014 00 Occupancy Type: ermit 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 WITBIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter LLED INSPECTION. upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Is Date: I2 I granting of this permit. Additionally,the applicant understands and will comply with �/ All roofs shall a inspected prior to roofing material being installed.If a roof is / installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER- 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. 1 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 nd 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 of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(See.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. S ignature Date CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10440 MANN DR DATE: 12/19/2014 REVIEWED BY: MELISSA APN: 326 45 014 BP#: "VALUATION: 1$11,394 xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDRE USE: PERMIT TYPE: WORK REMODEL E MASTER BATH 63 S.F. SCOPE vwma � r. bFc<ar r''.'��rt'rrE'ck Plrrtnl. Plrt1(�frrrch �:;,<c.1't< s �`ha<.�f Fee: f'tramb.Per-nzft J cc. )siatr ;vrcch. Inv, OtirerPlumb7n_rrr �)rr,eP!t - ?rtsp. 1'iawib. Ir€a . Fee: h7s'r. NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Theseees are based on the relimina in ormation available and are onl an estimate. Contact the Det or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/131 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 63 s.f. Remodel,Bath(<=300 sf) Suppl.PC Fee: (D Reg. ® OT 0,0 I hrs $0.00 $645.00 IREMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? ® Yes (j) No $0.00 G Advanced Planning Fie; $0.00 Select a Non-Residential 7i«}e'l 1)cac°ral?Icy?atrztzrrn T Building or Structure Strong Motion Fee: IBSEISMICR $1.48 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 $2.48 $645.00["' - Toz'AL FEE $647.48 .; Revised: 10/01/2014