15030106CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21610 EDWARD WAY
CONTRACTOR: THE BUILDING C
PERMIT NO: 15030106
OWNER'S NAME: BERRY WILLIAM E AND ODOM TERES
1826 STONE AVE
DATE ISSUED: 05/20/2015
OWNER'S PHONE: 4087251548
SAN JOSE, CA 95125
PHONE NO: (408)265-7500
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
❑ LICENSED CONTRACTOR'S DECLARATION
CONSTRUCT 2ND STORY ADDITION (50 SQ FT);
License Class Lie. #
REMODEL
MASTER BATHROOM (110 SQ FT): REMODEL MASTER
Contractor77"Ye 6(&V.- G CU Date �� 0�-
BEDROOM/STUDIO (482 SQ FT), INSTALL (26) LIGHTS
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: $85000
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
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: 35618014 00 Occupancy Type:
1 permit is issued.
APPLICANT CERTIFICATION
that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
y certify
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
180 DAYS FROM LAST CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
,
%41-7/ Date:
costs,
't understands and will comply
granting of this permit. AdditionallZ
Issued by: /�.9/`r
with all non -point source regulationrtino Municipal Code, Section
9 18.
Date /zd
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
❑ OWNER -BUILDER 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
1, 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
1 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 Quali tv,Management District I
Maniei ode, Chapter 9.12 and
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
will maintain compliance with the Cupertino
the Health &Safety Code, Sections 255/05, 25533, a d 5534.
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. 1 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
1 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 [he Cupertino Municipal Code, Section
Licensed Professional
9 18.
Signature Date
CUPERTINO
❑ NEW CONSTRUC'
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)77.7r3228- FAX ((4408) 777-3333 m buildinng(cDcuoertino.org
ION � AT)T)MnN ;W& T TFR e -,I 1, I 7 n 11rt11c111T F -111 rr
PROJECT' ADDRE — I APN, „ T� - --- .
I(oI �DwAD W ✓-J G"U%3,1
o�rnFR N Mx Ho
2�rn P"1J 5-V I A1 t2r k � 7 e7
STREET ADDRESS I CITY STATE, Zip. G FAX ,
S U
CONTACT NAME r/�y fb`V ITN PO J"I rj CJ�6 Al
W-
STREET ADDRESS �O 6•� `
�+ I Ip
CITY, ST.gTE, ZI t A
�F ?A t061kA
FAX.'
WTLR ' OdRvtR-BUILDER' ' ❑ OWNER AGEN-r ❑ COhTRACTOR ❑ CONrRACTOR:AGENI' ❑ ARCHITECT ❑ ENGWEFR . -,❑
._ . . DEVELOPER ❑ TENAIT
CO?. i RACTOR NAI, E LICENSE 'MBE LICENSE rl?E
t l� l �- f C d�M 0 ,v I 2 Z
BUS. LIC
COMPANY NAME S
E-MAIL
FAX qv �7Ile-
G� I- UIr01 0
0 6
STREET ADDRESS
1%�(~
CITY, ATEA --
9 A 0PI C. C S Z
PH d6 22216)
ARCMTECT/ENGI?'EERNAME LICENSE NUMBER
`RYPoty
BL'S.L[C'�
w4(, 46;-)-72.
I
COMPANY NAME
CL. STP,14c_ RL
E-MAIL
/ N_FU f2CL.S�.CD
Fax
STREET
CA-► t tip �^ f
QDRE
CITY, STATE, 7 -IP
9�oFs�
PHONE
1 _ _D
ti.�v.at_,c�- C�
DESCRIPTION OF WORK
1 a f d
Masse roo i,-,bu.� I�r�rw , _bed rag ►—. 1 2 • AOUI,4h,
41. f � a (i
'ELeG iCiy<< �F ury'Sl..s' ,
EXISTING USE PROPOSED LSE CONSTR. TYPE 4 ITO S
USE TYPE OCC. I SQ.FT. I VALUATION (a)
I v
E>gSTG NEW FLOOR DEMO TOTAL
AREA Z 4 36, I AREA 5 AREA ' jr Sn NET AREA S �
�J b 7�.,��
G �
t e
Z
`
�/
12 /
v
BATHROOM KITCHEN . T4 V
REMODEL AREA REMODEL AREA w (/� REMODEL AREA �7 H SMG
VP
PORC?} AREA DECK AREA TOTAL DEC\K/P�ORCH AREA GP' _E ARELq: DET.gCH
f�/"�q � ❑ATTACH
4'DWELLING ULTrS:
ISA SECOATI UNIT ❑ 1'ES SECOND STORY ❑YES
BEING.4DLED? E3 NO ADDITION? ONO
PRE -APPLICATION ❑ l r5 1F YES, PROVIDE COPY OF I IS THE BLDG AN ❑
P ONPLATAL /UAT :
I 1STO
`"�O
4 ,'},•n
By my signature below, I certify to each of the following: I am the property Owner or authorized agent to act on the property oWner's behalf. I haw read this
application and the information I have pr vided ' have read the Description of Work and verify it is accurate. I agree to co m ly with allapplicabie loca!
ordinances and state laws relating to b ' di co cti .. authorize representatives of Cupertino to enter the above-identn d prop e for inspection purposes.
Signature of App]icanUAgent: T Date: -�
SUPPLEMENTAL II\TFOR4ATION REQ D
C r PLAT:CHECKTlPEsk s'a
g.—y" " ^ M
New SFD or Multifamily dwellings:.4pply for demolition permit for
T
existing building(s). Demolition permit is required prior to issuance of building
t OPETHE COUM1R�BIISD
R TE4,
r PL.4t�RE��N i
sfw M4„v
°��
permit for newbuilding.,
❑�EAPRESStisv4
Et r
�ORiLER yrs
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if zny HazardousMaterials are being
r rsTND�RD ���
x, k��
I{'IW1RFts,�
used as part of this project.
—Copy of Planning Approval Letter Or Meeting with Planning prior to
submittal of Building Permit application.0
s,4R;} 3t +sSa�`i?nRYEn
ERDISTRIC� g`�
�._t:�'.�r..�•.csk'.sa.�'�zTr..�� �v`
;:S;IR01,11fE1tTALs.HE:4I,TA_
B1dg,?pp_2011.doc I'el'ised 06111/11
WN00
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
OCCUPANCY TYPE:
21610 Edward Way
DATE: 05/11/2015
REVIEWED BY: Sean
JimADDRESS:
APN:
BP#:
'VALUATION: $85,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
2nd Unit? Yes •• No
OTC? 0 Yes 0 N
PENTAMATION 1R3SFDADD
PERMIT TYPE:
WORK
CONSTRUCT 2ND STORY ADDITION 50 SQ FT); REMODEL MASTER BATHROOM 110 SQ FT :
SCOPE
REMODEL MASTER BEDROOM/STUDIO (482 SQ FT), INSTALL (26) LIGHTS AND ((7) OUTLETS p
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.t.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-B,IV,V-B
50
$1,091.00
IADDPLCK
$1,057.00
IADDINSP
Lar<., 111::1>. F'ee,
$0.00
482 s.f.
$503.00 1
Remodel, Other
IREMRESOTH
Permit Fee:
$1,057.00
Suppl. Insp. Fee.S Reg. 0 OT
0 0
hrs
$0.00
L_L3_j Electrical
$113.00 1BREMRECEP I Recep/Switch/Outlets
PME Unit Fee: ,
$0.00
PME Permit Fee:
$48.00
Coniruclion Tax.
TOTALS:
50
$1;091 00
$1,057 00
1
MEGIi, IItU +' Y� {� a� Yes
t t 'PN P 1 4i ,�
LTMB, HOURLY, 0 1'es'� Q Noy
gym.
q V
A F h r
EL ,i0[7iLY' 0 Yes Q`No
�, �. ,•�,
it
a:frr h. /'dcrr, Ci! k
Phlmh, Mop Chuck
Elec. Plan Check 0.0 hrs $0.00
.1.1'�u•i� Pc, ,mil Fe ,
1',111mb. 1'ermil i c :::
Elec. Permit Fee: IEPERMIT
Other Plum!)
Other Elea Insp. hrs $48.00
0.0
dea lr. 1r7.,U. I'Gcr:
%'hunt,, 1juP. F G:
Lar<., 111::1>. F'ee,
IVV7CI ]his estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta). These fees are based on the Drelilninary inlnrmalion availahle and Ore nnly an PCHMafe- ('nnfarf rhe TIeN Fnr nddn'l in(n
FEE ITEMS (Fee Resohltion 1I-053 Eff ' I:'13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$1,091.00
=1 s. f.
$645.00
Remodel, Bath (<=300 sf)
1REMRESBAT
Suppl. PC Fee: Q) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
482 s.f.
$503.00 1
Remodel, Other
IREMRESOTH
Permit Fee:
$1,057.00
Suppl. Insp. Fee.S Reg. 0 OT
0 0
hrs
$0.00
L_L3_j Electrical
$113.00 1BREMRECEP I Recep/Switch/Outlets
PME Unit Fee: ,
$0.00
PME Permit Fee:
$48.00
Coniruclion Tax.
9.clmitlislrtalirc Fc c':
1
0
G
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee. IPLLONGR
$7.00
Select a Non -Residential
Building or Structure
Q
0
i
Travel Documentation Fee: ITRAVDOC
$48.00
Strom Motion Fee: IBSEISMICR
$11.05
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$4.00
SIIBTL
$2266.05
$1,2
r.
$3,527.050TAS
Revised: 04/01/2015