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15080211CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19423 GREENWOOD DR CONTRACTOR: PERMIT NO: 15080211 �N�T� GT1df� ��/• OWNER'S NAME: NG REBECCA B ET AL +�� DATE ISSUED: 08/28/2015 OWNER'S PHONE: 4088327889 � Md PHONE NO: & ,O , b ,Q ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E] r TO CLEAR CODE ENFORCEMENT CASE: REMODEL (2) License Class� Lic. # o BATHROOMS (100 SQ FT); KITCHEN REMODEL (90 SQ FT). Contractor Date 1 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: $20000 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 Pabor Code, for the performance of the work for which this APN Number: 37504031.00 Occupancy Type: 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 DAYS FROM LAST CALLED 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 Issued by:�Ei/v % G� Date: GG �� granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per pertino Municipal Code, Section 9.18. 4�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, Section s 25505, 25533, and 34. Section 3700 of the Labor Code, for the performance of the work for which this 11 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 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 • buildingna cupertino.orct 150 ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ PEVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS I Q /}� ,�, �19Dr. /� N # �j, ( /'^ OWNERNAME , ` yl lVq ('(• PHONE /� Q [ 2 •��,(�/. V o Q U E-MAILv STREET ADDRESS 19Z[.23 O� CITY, STATE, ZIP In �y / `o `v FAX CONTACT NAME / On ' ` p, PHONE OR {+ �], � o6 (�� I E-MAILon5,u (9 L ON cam^ /! W 7 vl STREET ADDRESS 6 V �'^ j 'r� )I� CITY, STATE, ZIP �N� /( �J'(� FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT` CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARC=CT ❑`-ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 5 8/4 C04 ^� LICENSE NUMBER /_ o �, /� t/� LICENSE TYPE BUS. LIC # COMPANY NAME �+ Wr {J /n C J INCA / E-MAIL On(�s u(j� I bGl.Gdns�rut ' FAX h, COWN STREET ADDRESS •1}-6� O L Q ) 4 / 34 T !J V -4/34 CITY, STATE, ZIP J _ _ � �� 1 ri rr�� `�J'lNl ,� D PHONE p IX 7 9 /� i V as VV U a J ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE p DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE k STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM REMODEL AREA ! /DD KITCHEN REMODEL AREA �/O OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA . U DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT 0 YES SECOND STORY ❑ YES BEING ADDED? ONO ADDITION? ONO PRE -APPLICATION OYES IF YES, PROVIDE COPY OF PLANNING APPL # Fl PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO RECEIVBY: AL VALUATION: 7FDQ�Q 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 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 buil 'ng construction. I authorize representatives of Cupertino to enter the abov entifi d for inspection purposes. rryoplert/y ��. v!S^ Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _ New SFD or Multifamily dwellings: Apply for demolition permit forovER-THE-couNTER existing building(s). Demolition permit is required prior to issuance of building I BUILDING PLANREVIEW permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElSTA_NDARD ElPUBLICWORKS 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 El SANITARY SER'BR DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTI] BldgApp_2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION imADDRESS: 19423 GREENWOOD DR DATE: 08/28/2015 REVIEWED BY: SEAN Mech. Permit Fee: APN: BP#: *VALUATION: 1$20,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: flet. Insp. Fee PENTAMATION 1 R3SFDREM PERMIT TYPE. WORK To Clear Code Enforcement Case: REMODEL 2 BATHROOMS 100 SQ FT): KITCHEN REMODEL SCOPE (90 SQ FT). 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 addh7 info. FEE ITEMS (Fee Resolution I1-053 Eff LLJQ Alech. Plan Check umb. Plan Check 1s7ec. Plan Cheek Mech. Permit Fee: Plumb. Permit Fee Elec. Permit Fee: Other Mech. Insp. Other !Taub lisp.Li Oiher Elee. Insp. Alecb los!' Vc," Plumb, Insp. Fie: flet. Insp. Fee 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 addh7 info. FEE ITEMS (Fee Resolution I1-053 Eff LLJQ FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 100 s.f. $645.00 Remodel, Bath (<=300 sf) IREMRESBAT Supp/. PC Fee: Q Reg. OTTo hrs $0.00 PME Plan Check: $0.00 F-9-6-1 s.f. $645.00 Remodel, Kitchen (<=300 sf) IREMRESKIT Permit Fee: $0.00 Suppl. Insp. Fee.0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 (7onstruction Tax: Administrative Fee: 0 E) Work Without Permit? 0 Yes 0 No $645.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 0 i Travel Documentation r Strong Motion Fee: IBSEISMICR $2.60 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC$1.00 SUBTOTALS: $648.60 $1,290.00 TOTAL FEE: $1,938.601 Revised: 07/02/2015 COMNAI.INITY DRIELOPMENT DEPA BUILDING DIVISION - CUPERT APPROVED This Get of plans and specifications MUE ;c s ite durin construction. It is unlaw or alterations on same, or t1therofrorn, without approval from the E The stamping of this plan and specifica.ti b:; hx;Id to permit or to be an p.pproval of any provisions of any City C,dinanc BY%G DAJE PERMIT NO. _ Gj 1%_U VED AUG 2 g 2015 BY V OFFICE COPY F„t FLo, I �q--,)- 3 CrL'/'1 Cl elf Wo > zu R Yo ���� F v40-�-(gs 0� i - --120' n�+u --39" -- ---282-1 - 52Z„ 36" ' r_. 0 N + 24. DISHWBCF36R B33 �-,,.. W J � 0) -- I2 ' � N 60 I b 60 00 r m C N. M •.- M l 04 All dimensions -size designations I l;t)I'. H 12, B15, B18, This is an original design and must given are subject to verification on not be released or copied unless job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. k: 3_ Design 1 FEW 00 W Designed: 8/ Printed: 8/18. r ;U\ W M 1 M Q W CO CDW N N r N i All dimensions -size designations I l;t)I'. H 12, B15, B18, This is an original design and must given are subject to verification on not be released or copied unless job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. k: 3_ Design 1 FEW 00 W Designed: 8/ Printed: 8/18.