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15070165E CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21921 ALCAZAR AVE CONTRACTOR:1 a 5 /r. -, PERMIT NO: 15070165 OWNER'S NAME: HESHAM IBRAHIM DATE ISSUED: 07/23/2015 OWNER'S PHONE: 4082097476 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL �" 7 B 4U CONVERT/REMODEL HALL BATH TO MASTER SUITE & License Class Lic.# PO ADD Contractor_ Am ble-✓ (*,,Le4,c-e Date ?-234 - (N) HALF BATH IN (E) LAUNDRY AREA (100 S.F.). RELOCATE & REPLACE (E) FURNACE. RELOCATE & I hereby affirm that I am licensed under the provisions of Chapter 9 REPLACE (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 Sq. Ft Floor Area: Valuation: $10000 performance of the work for which this permit is issued. 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. APN Number: 35715099.00 Occupancy Type: 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 to building construction, and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM-LA7Sr FROM-LCALLED 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 b dry granting of this ermit. Ad itionall th licant understands and will comply g g P Y P P Y ssued __ ate: with all non -point ce r gulations p Cupertino Municipal Code, Section 9.18. Signature Date %-L�—L' ( 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. ❑ 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: I, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 I hereby affirm under penalty of perjury one of the following three California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices w ich emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay agement District I performance of the work for which this permit is issued. will maintain compliance with the C e, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sectio 2 Mic Section 3700 of the Labor Code, for the performance of the work for which thisOwner 23 �— permit is issued. 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 Lender's Address 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, ARCHITECT'S DECLARATION 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 ❑ NEW CONSTRTTCTTOV CONSTRUCTION PERMIT APPLICATION! COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (4018)1777-3228 e FAX ((408) 777-3333 • buildingPcut)et'dno.org 8) 1 1 1 nT)nrrr-r)"T F7 A T T,-„ . n (� PROJECT ADDRESS ]ij�? / / - — f c�vibIvly / J.hk1L xeli URICHNAL PERMIT n APN R ` I t, Y (e-''G?,2,rL -J 1 i ( 35 � / OWNER NAME j// / L=Cil IL l[5� PHONEf�G21G.'Ci4�roubliPi�s c��LL3�.0 fZ STREET ADDRESS, j / CITY, TATE, ZIP FAX ic(YIU 69 �(��. CONTACT NAME (j PHONE14�.��jE-MAIL STREET ADDRESS ` ` CITY`\ $'TATE, ZIP /�/( �l {7 FAX �W V <" ' f 6 Z 2 / OR'NER ❑. OWNER -BUILDER ❑ OWNERAGENT 4� CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME J // LICENSE TYPE BUS. LIC #LICEMNTSEMBER COIvfPANYNi� f�� ( /ILAX t ( (� J f�%E'?F !�E I1.YJ �CI-r��C 6.STREET ADDRESS STATE, ZIP PH0 ✓ J•-l'lr�j <.J ARCHITECT/ENGITiEERMAME d (•`I ��CA+� LICENSE NUMBER i ,( BUS. LIC COMPANY NAME �U bCS� L2 S __MAIL ✓ f 6-L FAX — STREET ADDRESS •� CrrY, STATE, ZIP PHONE DESCRIPTION OF WORK ' ! - 2u Y VJ�6 llrL� (<; a�cl t/^ i iE',t�vCe;/� f,�s%,,�� N��-v �•v�`��' ids, ��'C� .t��.r w 1� ,ff�� S! -7XISTING USE PROPOSED USE CONSTIL TYPE 4 STORIES I USE TYPE I OCC. SQ.FT. VALUATION (S) Tz)a TG AREA NEW FLOOR DEMO TOTAL AREA AREA NET AREA BATHROOM REMODEL AREA • `�^9�� KITCHEN M40DEL AREA OTHER REMODEL AREA - - PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH m DWELLD\'G=S: ISA SECOND UNIT []YES SECOND STORY AYES BEING ADDED? NO ADDITION? NO IVEDB'Y£,--_ - TOTAL VALUATION: PLANTING APPL R ❑ No PLATT'IN'G APPROVAL LETTER EICHLER HORSE? ❑ N PRE -APPLICATION ❑YES IFYES, PROVIDE COPY OF I5 THE BLDG AN ❑'YES�h.Rd By my signature below, I certify to each oft followin- am the property Owner or autrizaeent o acf on the property ovmef's behalf. I have read this application and the information I have provid d is co a t. I have read the Description of Vdork and verify it is accurate,,/I to agree comply with all applicable ]ocal ordinances and state laws relating to bu' tli/� ctlo I authorize representatives'of Cupertino to enter the above=ide tified property for inspection purposes. _const Signature of ApplicanUAgent: Date: u SUPPLEMENTAL INFORMATION REQUIRED ccx._t 3M-1. s 20UTII�G SLIP, _ New SFD or Multifamily dwellings: Apply for demolition permit forte r G ��g7JILDjI�GP1 existing building(s). Demolition permit is required prior to issuance of buildingSag Irl] OVER THECOURTER �4N;J2EVIEWF , permit for new building. M EXFRESS� . PLAhTII�GELfiANW Commercial Bldgs: Provide a completed Hazardous Mate rials Disclosure 5� sTq�DD C7 form if any Hazardous Materials are being used as part of this project. Y NYE _ Copy of Planning Approval Letter or Meeting with Planning to prior submittal of Building Permit application. fl oR M�� r� sAhTr�RY�sEvRDrsrrcr BIdgApp_2011. doc revised 06/21/11 CITY OF CUPERTINO FM -7 FFV F,9TI1MATnR _RTITT.nT1V!_' n7vicrnty VAADDRESS: 21921 ALCAZAR AVE DATE: 07/23/2015 REVIEWED BY: MELISSA APN:357 15 099 BP#: "VALUATION: $10,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: Suppl. PC Fee: (E) Reg. 0 OT PENTAMATION PERMIT TYPE: 1 R3SFDRE i WORK CONVERT/REMODEL HALL BATH TO MASTER SUITE & ADD N HALF BATH INE LAUNDRY SCOPE AREA (100 S.F.). RELOCATE & REPLACE (E) FURNACE. RELOCATE & REPLACE (E) WATER Mech. Plan Check0.0 hrs $0.001 Plumb. Plan Check 10.01 hrs $0.001 Elec. flan Check Mech. Permit Fee: iMPERMIT I Plumb. Permit Fee: IPPERMIT Islet. Perndi Fee: Other Mech. Insp.0.0 �hrs�$48.00 Other Plumb Insp. 0.0 hrs $48.00 Other Elec. lnsp.77— .;tlech. Ltsp� Fee: I Plumb. Lisp. Fee: I Elec. Insp. Fee: 1."-i �n; ints esumare aoes not inetuae fees aue to other Departments (ie. Planning, Public Works, Fire, Sanitary Sewer District, School District P.t['_)_ Thoco foot Nro uncoil — N,o n oliss.is.n...:..F . ..si....... ..77..f.1- —I - .. 1.... r+_— _ — _ - __. —_- _ —» FEE ITEMS (Fee Resolution 11-053 E f 7/1/13) FEE QTY EE MISC ITEMS Plan Check Fee: $0.00 = s.f. $645.00 Remodel, Bath (<=300 sf) IREMRESBAT Suppl. PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 1 # $143.00 1 Mechanical IMFR=<100 I Furnace, Forced -Air Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT 0,0 Ihrs $0.00 0 # Mechanical $72.00 IBREMAIR A/C Units (<=10K cfm) PME Unit Fee: $0.00 PME Permit Fee: -FT $96.00 0 # Plumbing $29.00 IPRWHEATR Water Heater Constriction Tar: Administrative Fee: ]ADMIN $45.00 0 0 Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure G 0 i Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $1.30 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS:.; $191.30 $889.00 -. TOTAL FEE.; $1,080.30 Revised: 07/02/2015