15080144CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21345 RUMFORD DR
CONTRACTOR.' PERMIT NO: 15080144
`
C.
OWNER'S NAME: AGRAWAL ADITYA & CHUNG MIIN Y TRUST
%Z W2904 6 DATE ISSUED: 08/19/2015
OWNER'S PHONE: 4082214214
airMINO CA 000q PHONE NO:
G LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
REMODEL GUEST BATHROOM (40 S.F.) AND MASTER
License Class_ Lic. #
BATHROOM (40 S.F.)
q
Contractor ��F�i u!� i �j Date g 1 2 D t
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
Sq. Ft Floor Area:
Valuation: $8000
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
APN Number: 32641046.00
Occupancy Type:
p y
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 D S FROM LAST CALLED INSPECT N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
(( - --- Q l5
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
9.18.
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.
❑ 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
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
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 the
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
I 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 /�i4 ! K /
permit is issued.
'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
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 non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building0cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESSAPN
2 1'
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OWNERNAME ty
PHONE l
E-MAIL
wad
STREET ADDRESS
CITY, STATE, ZIP �� iN ,� O �O
/�(/
FAX
CONTACT NAME
'1�4 is r4
PHONE
E-MAIL
STREET ADDRESS [�
CITY, STATE, ZIP
FAX
i
rl.I C�4
OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME K% Q N
LICENSE NUMBE
LICENSEE
BUS. LIC #
XE
COMPANY NAME
E-MAIL
FAX
K
STREET ADDRESS
CITY, STATE ZIP
or
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
D S2S F
.4rn em-kSteA f
EXISTING USE
PROPOSED USE CONSTR.
TYPE
#STORIES
I
US
TYPE
OCC.
SQ FT
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECKAREA TOTAL DECKIPORCH ARE
A GARAGE AREA: DETACH
ATTACH
N DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑YES
BEING ADDED? []NO
ADDITION? []NO
PRE -APPLICATION [:]YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
VED BY:TOTAL
VALUATION:
PLANNING APPL # []NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
t
By my signature below, I certify to each of the following: I am the property owner or authori d agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin construction. rize representatives of Cupertino to enter the above -id ntifie property for inspection purposes.
Signature of Applicant/Agent: Date: 2 7.10
SUPPLEME 0RMATION RED
PLAN CHECK TYPE
ROUTING SLIP
OVER-THE-COUNTER
�1 BUILDING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑. MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 Ldoc revised 06/21/11
CITY OF CUPERTINO 15D3044
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 ees are based on the preliminar information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7f 11/13)
21345 Rumford Dr.
DATE: 08/19/2015
REVIEWED BY: PAUL
1WADDRESS:
APN: 326 41 046
BP#:
"VALUATION:
1$8,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
$0.00
PENTAMATION 1 R3SFDRE
PERMIT TYPE:
WORK
Remodel Guest Bathroom 40 S.F. and Master Bathroom 40 S.F.
SCOPE
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.. These ees are based on the preliminar information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7f 11/13)
A:Iech..Plcaa Check
Plumb, Plan (.'heck
h;Iec. Plan Check
Mech. _
Plumb. Permit Fe,
Elec. Permit Fee:
Other A1ech. Irasp.
)!her Plumb Insp.
Other Elea Insp.
Rol
hrs
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.. These ees are based on the preliminar information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7f 11/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
80 s.£
$645.00
Remodel, Bath (<=300 sf)
IREMRESBAT
Suppl. PC Fee: (F) Reg. OT
Rol
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
( ajgjf i,`f l5l fcrp,.
0
E)
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential E)
Building or Structure
�
7ri���>l f)rac�t�t�a�nT�tiurf 1°ef>.�:
Strong Motion Fee: IBSEISMICR
$1.04
Select an Administrative It�� `
QjU. w
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2.04
$645.00
TOTAL FEE:
1 $647.04
Revised: 07/02/2015
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#A 10, COOL COMMUNITY DEVELOPOENT DEPA13TMENT
BUILDING DIVISI00,eWWajVa 1, O -J4'
APPRGIZED-m-t 1'�ks
Thl set of plans and specifications MUST be kept at the
CUPERTINO
Building Department
AUG 19 2015
IoS` REVIEWED FOR CODE CPMPL
11.1 .ail
FWiewed Y: --
Jo site during construction. It is unlawful to make any
changes or
t.fi erntions on same, or to deviate
,4 t h refrona, 4�oval from the Building Official.
rx" A.
The tamping of this plan and specifications SHALL NOT
e held to permit or to be an approval of the violation
0fr'I'Dv-srovislons of an Cit v Ordinance or -(Z+nt. Law.
BY
DATE A 11 q 16045
NO.
IANaE
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RECEIVED
AUG 19 2015
BY.....
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