15100051 AAL0 ft1Ac CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23704*@t1 9fA'CT UNIT VD10 CONTRACTOR:BAY AREA ENTERPRISE PERMIT NO: 15100051
OWNER'S NAME: REID GEORGE L AND MARY E TRUSTEE 2110 MANGIN WAY DATE ISSUED: 10/07/2015
OWN 'S PHONE: 6505371523 SAN JOSE,CA 95148 PHONE NO:(408)238-5043
A LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
DI I
UNIT 10-INSTALL 9(N)LIGHT FIXTURES,27
License Class Lic.#_
OUTLETS&2 BATHROOM FANS
Contractor Date 10 7–V 15—
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.
1 hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: Valuation:$2000
1. 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 APN Number:34254010.00 Occ upanc� I}pe:
performance of the work for which this permit is issued.
z. 1 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. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is 180 DAYS FRO LED INSPECTION.
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 savessue ate:
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. Additions y,the applicant understands and will comply with
all non-point source regulati ns the Cupertino Municipal Code,Section 9.18. RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
Signature Date t 7 installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER UILDER DECLARATION Signature of Applicant: Date:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 IIAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the
2. 1,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
1 hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District 1 will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety od ,Sections 25505,25533,and 25534.
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by Own r' d agent: ��/7/
Section 3700 of the Labor Code,for the performance of the work for which this 6 Date:
permit is issued.
3. I certify that in the performance of the work for which this permit is issued,I CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the orker's
Compensation laws of California. If,after making this certificate of exemption,I I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
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 Licensed Professional
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
CONSTRUCTION PERMIT APPLICATION
— COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 lVe�WFICUPERTINO (401)777-3228-FAX(408)777-3333-buildinata"Dcupertino oro[ 1NEW CONSTRUCTION ElADDITION TERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT N
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❑OWNER ❑ OWNER-RUILDFR ❑ OWNER AGENT L;a C NTRACf OR ❑CONTRACTOR AGENT ❑ ARCIIrrFcr ❑FNfiRdFF.R ❑ DrvELOPFR ❑TrV rr
CONTRACTOR NAME LICENSE BER LICENSE TYPE BUS.LIC#
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ARCHITEMENGINEER NAME LICENSE NUMBER BUS.LIC 0
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DESCRIPTION OF WORK t-'ED G "� t
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EXISTING USE PROPOSED USE CONSTR.TYPE N%70R1ES
USE TYPE OCC. SQ.Fr. VALUATION(S)
FXI.STG NFW FLOOR nFMn Tfrr41.
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODELAREA REMODELAREA
PORCH AREA DECK AREA TOTAL DECK/PORCII ARFA GARAGE AREA: DETACH
ATTACH
p DWELLING UNrIS: ISA SECOND UNIT YES SECOND STORY YPS
BI:IN(:AUUEU7 []NO AUDITION? NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDGAN YFS Y LUATION:
PLANNING ADPL M []NO PLANNING APPROVAL LETrER EICHLER HOM
By my signature below,I certify to each of the fo owing: I am the pro a caner o au on en t c property owner's behalf. I have read this
application and the information I have provided correct [ cad a Desc ork d accurate. 1 avec to comply with all applicable local
ordinances and state laws relating to buiIII o sWc[ion. I a resentat' of or,
t �e,-r the shove-identified property for inspection purrnses.
Signature of Applicant/Agent 1--t7 Date: j t I-7
SUPPLEM AL WFORMATIO REQ D PLAN CHECK TYPE R0tMNG SLIP
_New SFD or Multifa ily dwellings: Apply f r demolition perm) Or ❑ OVER-TH&COUNTER ❑ BUILDING PLAN REVIEW
existing building(s). Dc olition permit is rc ui prior to issuance of building
permit for new building. ❑ FxPRrsS ❑ r1.,���rtNc PL.tN,RrYTrw
—Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C1 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
ubmittal of Building Permit application. ❑ NWOR ❑ SANITARY SEWER DISTRIL-r
❑ ENVIRONMENTAL HEALTH
BldgApp_20/1.doc revised 06/2///1
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 23700 PALOMA CT# VD10 DATE: 10/07/2015 71 REVIEWED BY: MELISSA
APN: 342 54 010 BP#: 'VALUATION: 1$2,000
rPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY Multi-Family Dwelling Building is PENTAMATION 1RMAP8
USE: 3 Stories 0 Yes Q No PERMIT TYPE:
WORK UNIT VD 10 - INSTALL 9 N LIGHT FIXTURES 27 OUTLETS & 2 BATHROOM FANS
SCOPE
Mech. Plan Check 0.0 hrs $0.00 Elec. Plan Check 0.0 firs $0.00
FMech. Pennit Fee: 1MPER,111T F Elec. Permit Fee: 1EPERA11"1
Other Mech. Insp. 0.0 Iirs $48.00 Other Elec.Insp. LLO hrs $48.00
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 preliminari information available and are onl),an estimate. Contact the De t or addn 7 info.
FEE ITEMS Wee Resolution 11-053 QL 7/11,13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 2 1 # Mechanical
Suppl. PC Fee: Q Reg. O OT 0.0 1 III's $0.00 $50.00 I BREMVENF I Ventilation Fan
PME Plan Check: $0.00 9 Electrical
Permit Fee: $0.00 $72.00 IBREMFIXT Fixtures, Lighting
Suppl. Insp. Fee:O Reg. 0 OT FO 0 hrs $0.00 F27 Electrical
PME Unit Fee: $0.00 $83.00 1BREMRECEP I Recep/Switch/Outlets
PME Permit Fee: $96.00
oilsiri!r lion 10,
Administrative Fee: 1ADMIN $45.00 0
Work Without Permit? 0 Yes (D No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 18CBSC $1.00
SUBTOTALS: $190.50 $205.00 TOTAL FEE: $395.50
Revised: 10/01/2015