15110114L
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: .23637 BLACK OAK WAY
CONTRACTOR: S & B CONSTRUCTION PERMIT NO: 15110114
OWNER'S NAME SANJAY T I ANDON
1294 CALDWELL CT DATE ISSUED: 11/17/2015
OWNER'S PHONE,,'5103057430
SUNNYVALE, CA 94087 PHONE NO: (408) 529-1818
❑ LICENSED- CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
BATHROOM SHOWER.
REMOVE AND REPLACE MASTER
Class Lk 4
icense
contractorDate 15
hereby affirm that a, sed under the provisions of Chapter 9
lirenon
(commencing wit, ectiin
.7000) of Division 3 of the Business & Professions
Code and that my-licefise is in full force and effect.
I hereby affirm un"4eir penalty of perjury one of the following two declarations:
I have an&w.ill inaintaliva certificate of consent to self -insure for Worker's
Compensation, as provided foi by Section' 3700 of the Labor Code, for the
.;
Sq. Ft Floor Area:
Valuation: $5000
.ii. !_ - ...,
,performance of tfiework'fbvwhich this permit is issued.
have and'will maintain Worker's Compensation Insurance, as provided for by
.
fSectio : n 3700 of ih6i'abo'r Code,, for the performance of the work for which this
ATN Number: 34256018.00
Occupancy Type:
permit is is sued."
APPLICANT CERTIFICATION
I certify that I have read This application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I 4gree!to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon'th'e, above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless'the City of Cupertino against liabilities, judgments,
costs, ;and expenses'which may accrue against said City in consequence of the
-1 7
Issued by: .,� Date: // - // x /
granting of this, permit. Additionally,'the applicant understands and will comply
.1
with all non -point, source r ulat, the Cupertino Municipal Code, Section
ia.
9.18.
y:ons
ftignature Date 17./5
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
---77
❑ OWNER -BUILDER DECLARATION
I hereby 'a"M r fif . that I am exempt from the Contractor's License Law for one of
Signature of Applicant: Date:
the following two
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, a& owner of the, property,, or my employees with wages as their sole compensation,
will do; the work.1'and the -structure is -init,intended or offered for sale (Sec. 7044,
Business & Prbfessi6ns Code)
1, as owner of the', pr . o ; perty, I am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the 'project ($ec.70 * 44, 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. 1 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: .. 1.
I have and will maintain a Certificate of Consent to self -insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, � as provided for by Section 3 700 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.
Muni 'pal Code, Chapter 9.12 and
I
will maintain compliance with the CupertinoMuni
I have and,will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505,25 nd 25534.
3/
Section 37'.604the L Labor C6&Jor the performance of the work for which this
�wner __,,e
permit is issued. i
or authorized agent —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 la*s!6f 'California. , If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subjq�ct,to the . Workers 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
indemnify:a'ndke'ep'harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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
C;,
9.18, 1!
Signature Date
CONSTRUCTION PERMIT APPLICATION
COMMIUNl IY DEVELOP1,0ENT DEPARTMi�EN T • BUILDING DIVISION
10300 TORRE AVENUE • CUPER T INO, CA 08014-3255
CUPERT(h[O,
(408) 777-3228 • Ft' -,,X (408) 777-3333 • buildino(a�gljperino.ora
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Copy of PlaI g Approval Letier or 1\1eeting with Pearn r?� prior to
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rsy my S?gnacure DCl0VV, 1 Ce; lay :o eacn Or Lne :ollo-win?: i am in- propery owner or authon_eti
agent to act on the propel ty O'wmer's behal f' I have read this
.,-application, and the -information -I -have provided -is-eo�l-C-t.=l av ead the -Descriptio l of-�rT%ork and- >eri�� it=is accurate: I=armee tomo;reply �;ith all- pplicabte lotal-
ordinar,ces and state laws relating to illi construction, thorize representatives'oi Cup;.rtino to enter the above-identi led proper for inspection purposes.
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Copy of PlaI g Approval Letier or 1\1eeting with Pearn r?� prior to
submittal of Building P- nit application.
Blc'C�pp_2011.doc revised 06/21/11
•
CITY OF CUPERTINO
FEE ESTIMATOR BUILDING DIVISION
ADDRESS: 23637 Black Oak Way DATE: 11/17/2015. REVIEWED BY: Sean
APN:BP#: *VALUATION: 1$5,obo
,
*PERMIT. TYPE: Building Permit PLAN CHECK TYPE: Alteration Repair
PRIMARY PENTAMATION
,... . :SFD or Duplex 1GENRES
USE:::..: PERMIT TYPE:
woRK. Remove and replace master bathroom shower.
SCOPE
Afech lial.n (,'Aw-k
L!''ech, erw*iL[`&-1e,,
ff
Afech, .'K�
PlluriL but",
Elec. Pepwdf 1,-ee:
NOTE.-; This estimate. does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). 7 These fees are based on the preliminary information available and are only an estimate. Contact the Dept for aaan't info.
FEE' ITEMS' (Fee Resolution 11-053 Eff. !LII�13
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: .: .:'Hourly Only? 0 Yes (E) No
$0.00
= hours
$0.001
Plan Check, Hourly
Suppl. PC Fee: (j), Reg.' 0 OT
0.0
hrs
$0.00
PWtPlan'Check:,:,-,;
$0.00
Permit Fe.'d:':, Hourly Only? OYes (DNo
$0.00
Suppl. Insp.Tee:(j) Reg. 0 OT"00
hrs
$0.00
PMEE Unit Fee:
$0.00
PMEE Permit Fee'.
$0.00
Work - Without Permit? 0 Yes No
$0.00
Advanced P . lanning-F ee:
$0.00
=hours Inspections
$286.001 ISTINSP Inspection, Hourly
7,11(ji,elDoe'un'i . enfdtion Fees:
Strong Motion Fee" IBSEISMICR
$0.65
Select an Administrative Item
81dg.;Std§ Commission mission Fee: IBCBSC
$1.00
.. . .. . .. ......
. ...... ..
SUBTOTALS
$1.65
$286.00
TOTALJp
, -
$287.65 1
Revised: 10/01/2015