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14110099 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21411 VAI AVE CONTRACTOI_ 7j /j e N 1)6yj- PERMIT NO: 14110099 OWNER'S NAME: PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL ❑ ,-AV p REMODEL 2(E)BATHROOMS,NO STRUCTURAL License Class_�� Lic.# J0�l/f/5 CHANGES(95 Contractor ��► � &61 Jets Date/� aA S.F.) 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:$20000 !� 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:36205017 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 18 F 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 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 Iss y: Date: with all non-point sou ations per the Cupertino MunicipalC de,Section 9 18. RE-ROOFS: Signature Date r 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 Baya Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cu o Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5 25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this ( // permit is issued. Owner or authorized agent: Date: !!' 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 00�COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTiNO (408)777-3228•FAX(408)777-3333•building(a cupertino.org \ ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS )-P///- VAI 6 / �a p6ar f APN# ^] (Z 6S 013 OWNER NAME VAIV 4 ' 6 CITY, STATE,ZIP (lf� (/� FAX / CONTACT NAME j / Q Jho AAA PHONE� ) �L �� E-MAIL STREET ADDRESS //�^�C JVI) � 1/' I/ CITY,STATE,ZIP �r l <�urd a L��M FAX / ❑ OWNER El OWNER-BUILDER e❑ OWNER AGEENTU ElCONTRACTOR El ❑CONTRACTOR AGENT ARCHITECT J❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME A/� i l�jl�,�I yy� LICENSE NUMBER O� 71 t1( / LICENSE TYPE BUS.LIC# COMPANY NAME I ///V` R /�`�l�(�j��V I ' E-MAIL FAX STREET ADDRESS / �C0/ U(�j��(/J�, CITY,STATE,ZIP �f ly��(I}��/` /J I� PHONE ARCHITECT/ENGINEER NAME (� yJ LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK �y �/1 �l �/,�,��n nq_ VAJ k �✓1 I ,�//I_ hq�/ hV� �xG(rU �L-�TK� IiV�� rod v�� RU FABS EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL ,p AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: LJDETACH ❑ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY [:]YES BEING ADDED? []NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES „ VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑N ' e. agree 4 a By my signature below,I certify to each S” the following: I am the property owner ora horized ct on the pro a er s e f-I have read this application and the information I have ided is correct. I have read the Description of an veri it' I to comply with all applicable local ordinances and state laws relating to d' g construction. I authorize representatives of Cupertino to enter the above-I ntified `roperty for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED . .,ROUTIN SE ,z,w r .: New SFD or Multifamily dwellings: Apply for demolition permit for x R TH1iC OTJNTERi� ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of buildingKZZ 4 z ` permit for new building. r0 ExI;REs r f PLAlanmcPLANREVIEw _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sTAi\ntD { 1] ruBLlcwoRxs form if any Hazardous Materials are being used as part of this project. } ,❑ ,L�jE��'a�r r• ❑�BIREbEPT x _Copy of Planning Approval Letter or Meeting with Planning prior to - i ❑ WITARY SEVS ERDISTRICT: submittal of Building Permit applications :L1NVIRONMENTAti`HEAI,TIi'.`>t B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21411 VAI AVE DATE: 11/18/2014 REVIEWED BY: MELISSA APN: 362 05 017 BP#: "VALUATION: 1$20,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM USE: I PERMIT TYPE: WORK REMODEL 2 E BATHROOMS NO STRUCTURAL CHANGES 95 S.F. SCOPE U-"41. Plan C'htct.h I'lrunh. Plan Ctccii 1'er•nril Feet l'lunzh. Per mil hee: t,; >car_ (J;i c r /ccdr. l;syr. Oth, F'ium1J trrsn. Li ()r?>e: 1-1:r. ins;>. i'`, at.Insp. l'ec: I'lttrnb. Insp. Fee: f_:uzc-1;ifs 1 ec: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prelimina information available and are only an estimates Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Elf. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 95 s.£ Remodel,Bath(<=300 sf) Suppl. PC Fee: 1@ Reg. 0 OT 0.0 hrs $0.00 $645.00 IREMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. ® OT O p hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? ® Yes (E) No $0.00 E) Advanced Plannin&Fee: $0.00 Select a Non-Residential E) Building or Structure 0 Ii-t��>��/1?r>l°tt.tar:tlttt�trart Fees: � Strom Motion Fee: 1BSEISMICR $2.60 Select an Administrative Item 1314y,Stds Commission Fee:. IBCBSC $1.00 $3.60 $645.00 TOTAL FEE: $648.60 Revised: 10/01/2014 RECEIVED f C:7)j Rope cq_� h ply m b in - pew Window- m S 0C4 +17 �, n-3; CD COMML LAITY DEVELOPMENT DEPARTMENT T BU LING DIVISION - CUPEP.TINO C APPROVEDrn CL This set of plans and specifications%vjST be kept at the 5 m c� job site during 5. construction. Itis unta fui to make any O changes or alterations on same, or to deviate therefrom,without approval from the Building Official. in of this plana ".cat,ons SHALL NOT The Stamping approval of the violation OFFICE be held to per o' t' COPY ina;lce or State Law. of an DATE PERMIT# y