15070168V
I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 21686 OLIVE AVE I CONTRACTOP qe I? /ii` 19cCd I PERMIT NO: 15070168 I
OWNER'S NAME: XIAO MED{IAN AND TROTTER MICHAEL L I I DATE ISSUED: 07/23/2015 1
I OWNER'S PHONE: 4084828149 1 , I PHONE NO: I
LICENSED CONTRACTOR'S DECLARATION
License Class Lic.# 7–q 94 U 3
Contractor Date
I hereby affirm that Ii. 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.
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
permit is issued.
APPLICANT CERTIFICATION
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
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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date — V–�
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
CONVERT (E) GRAND ROOM IN TO 2 (N) BEDROOMSZ(368
S.F.) (WINDOWS WILL MEET EGRESS AS REQUIRED BY
CODE) & REMODEL (E) HALL BATH (60 S.F.)
Sq. Ft Floor Area: I Valuation: $12000
APN Number: 35721012.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PE IT ISSUANCE OR
Z180DAYS_FRO \LED INSPECTION.
I --Date:
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(x) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Munic' al Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505,25 y
5505,25533 d 25534.
Owncr or authorized agent: Dater
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I mustI 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
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
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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 �a
(408) 777-3228 • FAX (408) 777-3333 • building�cupertino.ong /ro
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT 9
PROIECf ADDRESS 0
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APN # 2 5 7- - Z - t _ o r -2-
OWNER
OWNER NAME
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❑ OWNER R OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME -
LICBNSENUMBE LICENSE TYPE /
BUS. LIC#
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COMPANY NAME
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ARCHITECTIENGINEER 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 (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
--
BATHROOM
KITCHEN
OTHER
REMODEL AREA •O
REMODEL AREA
REMODEL ARE
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
I
#DWbT,LINGUNITS:
ISASECOND UNrr ❑YES
SECONDSTORY ❑YES
BEING ADDED'. ❑NO
ADDITION? [:]NO
_
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN E] YES
OTAL VALUATION•
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
'
By my signature below, I certify to each of the following: I am the property o t r or authorized aeent to act on the pr a owner's behalf. I have read this
application and the information I have is correct. I have the D iption Work it is
provided read of and verify ate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize r e ntatives'of Cupertino to enter the above -identified property for inspection purposes.
SipatureofApplicant/Agent: Date:
SUPPLEMENTAL INFORMATION U D
e '
LAIC ....T1P�e
:ROUSING
OVER H)< OUNTER ?
IN,
s ,w• t
?� BUIL
New SED or Multifamily d%vellinQs: Apply for demolition permit for
PP Y P
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
J
Excess
M.
' ,
e- Egg
ca '
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
= �srgr�AxD��IIBvso
form if any Hazardous Materials are being used as part of this project.
Copy of Planning Approval Letter or Meeting with Planning prior to�
6
,�
ImeoRn'
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submittal of Building Permit application.
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�SAT�Tr7U2Y SEFiRDIST
011m�3.iaL:I�AL�rHxz �
BldgApp_2011.doc revised 06/11111
CITY OF CUPERTINO
IM I FEE ESTIMATOR - BUILDING DIVISION
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 preliminary information available and are only an estimate. Contact the Dept for addh 7 info.
FEE ITEMS (Fee Resolution 11-053 E : 7/1/13,)
21686 OLIVE AVE
DATE: 07/23/2015
REVIEWED BY: MELISSA
AWADDRESS:
APN: 357 21 012
BP#:
*VALUATION:
1$12,000
°PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE: p
PENTAMATION
PERMIT TYPE: 1 R3SFDRE ;
WORK
CONVERT E GRAND ROOM IN TO 2 N BEDROOMSZ 368 S.F. WINDOWS WILL MEET
SCOPE
EGRESS AS REQUIRED BY CODE) & REMODEL (E) HALL BATH (60 S.F.)
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 preliminary information available and are only an estimate. Contact the Dept for addh 7 info.
FEE ITEMS (Fee Resolution 11-053 E : 7/1/13,)
d:lech. Plan Che,
Plumb. Pla _
klec. Plan Check.
Wech, Permittee:
Plumb. Permit Fee:
F'lec. Permit Fee:
'cher r14ech. lrtsp•
'cher Plurreh Izzsh�.Li
Other Elec, ii:sp Li
Suppl. PC Fee: (F) Reg. () OT
mb
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 preliminary information available and are only an estimate. Contact the Dept for addh 7 info.
FEE ITEMS (Fee Resolution 11-053 E : 7/1/13,)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
368 s.f.
$503.00
Remodel, Other
IREMRESOTx
Suppl. PC Fee: (F) Reg. () OT
F0,0Thrs
$0.00
PME Plan Check:
$0.00
60 s.f.
$645.00
Remodel, Bath (<=300 sf)
IREMRESBAT
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. 0 OT
To.o
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
onstruction Tax.`
f4ministrative Fee:
Q
0
Work Without Permit? Yes No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Q
i
Travel Docurnentatiotvfee.�
Strong, Motion Fee: IBSEISMICR
$1.56
Select an Administrative Item
-7
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2.56
$1,148.00
TOTAL FEE:
$1,150.56
Revised: 07/02/2015
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