15030012 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22330 HOMESTEAD RD APT 120 CONTRACTOR:GLENN DAVIS PERMIT NO: 15030012
OWNER'S NAME:
PALM SPRINGS,CA 92262 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL F1 COMMERCIAL
APT 120;KITCHEN REMODEL 70 SQ FT;REPLACE(8)
License Class Lic.# RECESSED LIGHTS; (4)SWITCHES IN(2)BEDROOMS
Contractor 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 Valuation:$8000
performance of the work for which this permit is issued. Sq.Ft Floor Area:
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:32659020.00 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 FR ST CALLED INSP TION.
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 Cupertino Municipal Code,Section
918.
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.
a� OWNER-BUILDER DECLARATION Date:
Signature of Applicant:
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) HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,am exclusively contracting with licensed contractors to
co ct 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 h reby 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 A�and maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
1. 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 .1 and
performance of the work for which this permit is issued.
the Health&Safety CodeStions5505 5533,and 25534.
I have and will maintain Worker's Compensation Insurance,as provided for by
, r-+
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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 the Cupertino Municipal Code,Section Licensed Professional
918.
Signature Date J
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 22330 homestead rd apt 120 DATE: 03/02/2015 REVIEWED BY: Mendez
191APN: BP#: *VALUATION: $8,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION 1 R3SFDREM
USE: SFD or Duplex PERMIT TYPE:
WORK a t 120; kitchen remodel 70 sg ft; replace 8 recessed lights; 4 switches in 2 bedrooms
SCOPE
11
.3 �O.,, e
l9ech. Nlcrrr Check Plzunb. Plan Cheek Elec.Plan Check 0.0 hrs $0.00
;Meeh. Permit I%ee' Plumb. Permit Fee: Elect.Permit Fee: IEPERMIT
Other;1 pec h. Insp. Other Plumb In'T. ET-t- Other Elea Insp. 0.0 hrs $48.00
,lech. /rasp_ Fee: Phimb. hasp. Fee: t'lec.lrup. Fee:
NOTE:This estimate does not include fees due to other Departments(i.e 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 Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7ff /1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 70 S.f. Remodel,Kitchen(<=300 sf)
Suppl.PC Fee: (E) Reg. ® OT 0.0 hrs $0.00 $645.00 IREMRESKIT
PME Plan Check: $0.00 4 1 Electrical
Permit Fee: $0.00 $48.00 1 1BREMRECEP Recep/Switch/Outlets
Suppl. Insp. Feer Reg. ®OT Q,Q hrs $0.00 ® Electrical
PME Unit Fee: $0.00 $72.00 ]BREMFIXT Fixtures,Lighting
PME Permit Fee: $48.00
C.'onstraaclion Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? ®Yes (E) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Building or Structure 0
Travel Documentation Fee: ITRA VDOC $48.00 _T= A
Strom Motion Fee: IBSEISMICR $1.04 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$143.04 $765.00 " fi nT�° z1LFEE: $908.04
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Revised: 02/14/2015