15090095I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 19665 MERRITT DR I CONTRACTOR: CALIFORNIA SKYLIGHTS I PERMIT NO: 15090095
I OWNER'S NAME: LAM VERONICA H 11279 RUNSHAW PL I DATE ISSUED: 09/15/2015 1
OWNER'S PHONE: 4088889615 1 SAN JOSE, CA 95121 1 PHONE NO: (408) 482-6877
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # �3 3
I 3&14ey t
Contractor S1ec�7T/Al?1S 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.
1 hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self -insure for Worker's
n, as provided for by Section 3700 of the Labor Code, for the
of the work for which this permit is issued.
2 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
permit is issued.
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicanjunderstands and will comply with
all non -point sou re lations per the Cup ' o Municipal Code, Section 9.18.
Signatur i Date /S e�-d!S
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
t. 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
performance of the work for which this permit is issued.
2. 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
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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
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,
costs, and expenses which may accrue against said City in consequence of the
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.
Signature Date.
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
BATHROOM REMODEL (60 S.F.) AND CLOSE OUT (E)
BATHROOM DOOR TO THE EXTERIOR AND ADD A (I)
EXTERIOR WINDOW
Sq. Ft Floor Area: I Valuation: $20000
APN Number: 31635004.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM
OM LAST CALLED INSP:
EC ION.
l�tl�tJ/
Issued by.. Date
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505,,2M3, and 25534.
-T "s--
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CONSTRUCTION PERMIT APPLICATION 150RCO(5
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • building(Dcupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ALTERATION/T1 ❑ REVISION /DEFERRED ORIGINAL PERMIT„
PROTECT ADDRESS APN 9 OC
7
OWNER NAME, &, NE
tt80 O p p
A)IC/4 /� 4M 8) " 9 `'� E-NLSIL
G
STREET ADDRESS
CITY, STATE, ZIP FAX
IV 66S M
cu Ti -1 C�
CONTACT NAME PHONE E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT E3 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAN ,,,__ LJ CEN NUMBER LICEN TYPE
BUS. LIC f<
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE�ZIPos
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTIO OF WORK
04L i4 N _ d - G'b ' -- ��%� � CI A,v I z l /Lt7- c -J 40,SK_
< via a 7'x IEiZ.yi? Jo c,, f►?!f .� �,y��T
Eh7STING USE PROPOSED USE CONSTR T1PE
r STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (Si
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
."
—
BATHROOM
KITCHEN
OTHER
REMODEL AREA ,�;Q
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH ARE
GARAGE AREA: DETACH
ATTACH
I
k DWELLING UNITS:
IS A SECOND uNrr ❑ YES
SECOND STORY ❑YES
BEING ADDED? []NO
ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
PLANNINGAPPL9 ❑NO PLANN`ING APPROVAL LETTER
IS THE BLDG AN ❑ YES
EICHLERHONSE? NO
C D BY
=
TAL VALUATION:
.
By my signature below, I certify to each of the following: I am the property owner or authorized aeent to act on the property ovmer's behalf. I have read this
application and the information I have provide is correct. I have Desc ' on of Work and verify it is accurate. I agree to comply with all applicable local
saddthe
ordinances and state laws relating to onstruction. I authe entatives of Cupertino to enter the above-ider;tified pr perry for inspection purposes.
Signature of Applicant/Agent/ Date:
SUPPLEM TAL INTFOR.NIATI,6N REQUIPID .
I'1N CHECK
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.
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
-
form if any Hazardous Materials are being used as part of this project.
_ Copy of Planning Approval Letter or Meeting with Planning prior to
—.
submittal of Building Permit application.
rcuN�,r1r i ,i_I
B ldgApp_2 011. do c revised 06/21/11
CITY OF CUPERTINO t5QIX 5—
FEE ESTIMATOR — BUILDING DIVISION
iaADDRESS:
19665 Merrit Dr.
Plumb. Plan Check
DATE: 09/15/2015
REVIEWED BY: PAUL
Plumb. Peraaait Fee:
l APN: 316 35 004
Other Mech. Insp.
BP#:
*VALUATION:
1$20,000
PERMIT TYPE: Building Permit
taec.!'ce-
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
PME Plan Check:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
Bathroom remodel 60 S.f.
and Close out E bathroom door to the exterior and add a N exterior
SCOPE
window
Suppl. Insp. Fee:Q Reg. () OTQ
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 addh 7 info.
FEE ITEMS (Fee Resolution I1-053 Eff. L/03,
.,leech. Plena Check
Plumb. Plan Check
Llec. Plan Check
Afech. Permit Fee:
Plumb. Peraaait Fee:
Elec. Permit Fee:
Other Mech. Insp.
Other Plumb lnsp.
—1 —
Cher Elec. Insp.
Ll L
IA""ta_ ln��>. FEze
m'� /s cr>. V'v-
taec.!'ce-
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 addh 7 info.
FEE ITEMS (Fee Resolution I1-053 Eff. L/03,
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
60 s.f.
$645.00
Remodel, Bath (<=300 sf)
IREMRESBAT
Suppl. PC Fee: 0 Reg. 0 OT0.0
1 hrs
$0.00
PME Plan Check:
$0.00
=#
$503.00
Window / Sliding Glass Door
I WINNEWNST New (Non -Structural)
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. () OTQ
Q
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
(Amstruction Tax:
Aclministrtilire Fee:
0
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
i
Travel Documentation Fees:
Strong Motion Fee: 1BSEISMICR
$2.60
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS: T
$3.601$1,148.00
TOTAL FEE:
$1,151.60
Revised: 07/02/2015
n
i,
CUPF-RYINO
l�
Building Department
_
SE 2015
P 15
REVIEWED FOR CODE COMPLIANCE
Reviewed By:-f4LLlj
-
COMMBUU
NT
G DIVISIODEVELOPN CUP
HT NO
This1 set of plans and specifications .
during- construction. it is u
UST be kept at die
la Oul to make ur
1
job site;
changes or alterations onsam
without approval from i
, or to deviate
ie Building Official.
therefrom,
The, stamping of this plan and spec'
ications SHALL NOT
on
be held to permit orto be an app val'of the vio .tion
of�bprovlt�,�J6�dl f nCity •Ordinance or: a.e
RECEIVED
{,
BY
SEP 15 2015
DATE
PERMIT NO.
BY
Vt
t.�c_e_ 0
.
r�� CUPERTINO
vE2mN i c.4 Building Department
SEP 15 2015
^REVIEWED FOR CODE COMPLIANCE
Reviewed BY: Tft-iu 1(Lid