15060056 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21861 MCCLELLAN RD CONTRACTOR:UNITED FIELD PERMIT NO: 15060056
REMODELING DBA
OWNER'S NAME: LUCAS MICHAEL E AND SHERRY S 17855 VANOWEN ST DATE ISSUED:06/08/2015
ONV ER'S PHONE: 6506447674 RESEDA,CA 91335 PHONE NO:(818)402-5656
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COh1Iv1ERCIAL
KITCHEN ADDITION& REMODEL(311 S.F.),BATHROOM
License Class Lic.# _o� 12— REMODEL(50 S.F),OTHER REMODEL AREA(200 S-F),
I CONSTRUCT NEW FRONT ENTRANCE,REPLACE(8)
Contractor r,`r1�� r,[I �t.n a d�•pat / "p— EXISTING
1 hereby affirm that 1 am licensed under the In sions of Chapter 9
(commencing with Section 7000)of Division 3 oj},,e 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:
1 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
e ormance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$40000
" t 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:35714005 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 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 FROM LAST CALLED INSPE TON.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, (! O ��'
costs,and expenses which may accrue against said City in consequence of the : L`l`^ ®ate:
granting of this permit. Additionally,the applicant understands and will comply (J
Issued by
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature D / All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,l agree to remove all new materials for
inspection.
❑ 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
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)
1,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 tite air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent a e•
permit is issued.
1 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 1 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
1 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
[a COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 IS06/�5
(408)777-3228• FAX(408)777-3333•building(a)cupertino.org �J (0
CUPERTINO
[:1NEW CONSTRUCTION [3/
ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS ^ t o G I ^^ CCI N n APN#
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OWNER NAME rf•1 G'�.l f"l (� PHONE 6 y L/ E-MAIL
STREET ADDRESS 21.$61 11 `C C(e- le, N 2 CITY, STATE,ZIP e ( ,1 v FAX
CONTACT NAME I ®. s PHONE �Dc6 Z v�e7��� E-MAIL �l)�l✓I S�{a71-c
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❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT W C'OINTRA[["CTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMELIYENS$NUMBER � LICENSETYPE BUS.LIC N
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ARCMXCT/ENGINEER NAME ' LICENSE NUMBER BUS.LIC N
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DESCRIPTION OF WORK
EXISTING USE PROPOSED USE CONSTR TYPE HSTORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL t'
ARE AREA
BATHROOM KITC '� ? O
REMODEL AREA 5 DEL AREAS MODEL AREA
POR A DECK AREA TOTAL DECK/PORCH AREA A: El DETACH
❑ATTACH
d DWELLING UNITS: IS A SECOND UNIT []YES SECONDSTORY [I YES
BEING ADDED? []NO ADDITION? ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES �� �,Y+3s _ro f2 is of} ` 1; TOTAL VALUATION:
PLANNING APPL W ❑NO PLANMNG APPROVAL LETTER EICHLER HOME? NO
By my signature below,I certify to each of the following: I am the property owner or authorized agent t ct the property owner's behalf. I have read this
application and the information 1 have provided is correct. I hav read the Description of Work and veri Is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. la t orize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Dat
U�
SUPPLEMENTAL INFORMATION REQUIRED `cctcTYPE,ry °,Us ;1„t.tKRotir>tics >PztN w a
New SFD or Multifamilydwellings: Apply for demolition permit for „�4' 'x s``MSA`
a z sut+
g PP Y P C!VERT1 Y�BUII,DINGPLANREVIEW3 > '
existing building(s). Demolition permit is required prior to issuance of buildingnv �'€� yl4�ttri }r1�” yna�,� reg
r` r
permit for new building. k®{{SE s ' ” �D LVA
FT
existing
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Ia�ylcc4h' 1 a .�trnY.rs ti�I,+r S�k.Y w.#`3 ,¢tPj 4Erfi#yC'�
z,.'+ ate y`'_3"` 3fi # % fa -F�''YYa'c P.� II-+'.,, ,,�
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 6 Ar+%MWISD`A'RD `IGIT�,�, O� BlJcwoxxs
Y g P project.
r w� �V YY {y�TF � ry7hiyF� �� s{z "3r� �t
form if an Hazardous Materials are being used as art of this
vi11�3f ii�H'jiYi �.u'�Y'tx 7 �5 }' ,,.fir{lUi�'{` ���SyMfY`vl �ks.ti�T' v:.
_Copy of Planning Approval Letter or Meeting with Planning prior tofo
}Int MAOR 'Lrt 2, Eb} § ti v` IT 13th SEWDISTRICP
submittal of Building Permit application.
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21861 MC CLELLAN RD DATE: 06!08!2015 REVIEWED BY: PAUL
APN: 357 14 005 BP::, ! ._1 'VALUATION: $40,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY2nd Unit? •,Yes No PENTAMATION 1 R3SFDADD
USE: . SFD or Duplex OTC? 0 Yes QNo PERMIT TYPE: e
WORK Kitchen addition & remodel 311 S.f.), Bathroom Remodel 50 S. Other remodel area 200 S.
SCOPE Construct new front entrance, Replace (8) existing window, Install (2) new windows in living room
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. (s.Q
R-3 (Custom) II-B,111-B,IV,V-B 311 $1,626.0 IADDPLCK $1,323.00 IADDINSP
TOTALS: 311 $1,626.00 7f;`F°', 'hF2'k';Ss $1,323.00 F
5 �Io >PLUMB;HOURT.Y es'a Q o>, C,,$ URLY; No
MECHx HO'U4-RLY �3Yes O r 1' t EL
t «F
llc rlr. Plan i In:ck
Ph/111h, Plorl("hcN, file('. I'I(7n C Irt':ac
,, Nlurrrll. Pcr-nur Fri:: l;h:c• PL(rnrir 1�Lr'
Lj
!J;ltrr 1lrch, ,rr,c;:
ofhcr Phmab hasp. Uihc r face. l rs/.>.
rec: Phwil). hrsp. Pet,
NOTE: This estimate does not include fees due to other Departments(Le.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 addn'l info.
FEE ITEMS (Fee Resolution 11-053 Efl.' 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $1,626.00 = s.f. Remodel,Bath(<=300 sf)
Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 $645.00 IREMRESBAT
PME Plan Check: $0.00 200 I s.f. Remodel, Other
Permit Fee: $1,323.00 $431.00 1REMRESOTH /
Suppl. Insp. Fee-.(F) Reg. 0 OT 0,0 hrs $0.00 = # Window l Sliding Glass Door
PME Unit Fee: $0.00 $574.00 IWINREP Replacement
PME Permit Fee: $0.00
t urrstruclion 7'1?.\"
[clllir;)i.1/r(rt;L•L�1'Lre:
C
Work Without Permit? 0 Yes E) No $0.00 E)
Advanced Planning Fee: IPLLONGR $43.54 / Select a Non-Residential 0
Building or Structure 0
7:1-4/v,l Dnr.'r.ttrwnluliorr 1''c'us: A
Strong Motion Fee: IBSEISMICR $5.20 l Select an Administrative Item
Bldg;Stds Commission Fee: IBCBEC $2.00
r°,; " SUBTOTALS $2,999.741$1,65 0.00 ` r TOTA°L FEE $4,649.74
Revised: 05/07/2015