15100126 (2)CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10294 DEMPSTER AVE CONTRACTOR: KITCHENS BY MEYER PERMIT NO: 15100126
OWNER'S NAME: VAN DEN CROMMENACKER JOHANNES T AND 1 861 E EL CAMINO REAL ! DATE ISSUED: 10/15/2015 1
OWNER'S PHONE: 4084580110 1 MOUNTAIN VIEW, CA 94040 1 PHONE NO: (415)968-8318
LICENSED CONTRACTOR'S DECLARATION
b._
License Class 1 ~, Lic. ,#
Contractor(A 1rvr x <: 26 f jj SR53
I hereby affirm that I am liven ed 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:
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
performance of the work for which this permit is issued.
DIhave and will maintain Worker's Compensation Insurance, as provided for by
ection 3700 of the Labor Code, for the performance of the work for which this
rvermit 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. rally, t applicant understands and will comply with
all non -poi' sour egu ons pe ertino Municipal Code, Section 9.18.
Signature of - ate
❑ " OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
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:
i. 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.
s. 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 ❑
INSTALL 2 (N) 15 AMP CIRCUITS IN 2 BATHROOMS FOR 2
NEW WASHLETS
Sq. Ft Floor Area: I Valuation: $950
APN Number: 32647072.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
t/
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,,!�ections 25505, 25533, and 25534.
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
............... - ...... _.........
GENERAL PERMIT APPLICATION
COMMUNI T Y DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 i ORRE AVENUE - CUPERTINO, CA 95014-3250-
(-4,08)
5014-3255(408) 777-322.8 - FAX (408) 777-3333 - buildino(G-)CUCertino.orq
C1JP=—RT1N0-
. m I
XPLUIA-BING ❑ MECHANICAL R=C=CAL hfISCELLAN OUS
ITF7-0j-
cr ADDRESS C� if-�►-(� s I �P?• J .��� �i-� q0( .
Oi�TtR NAl�^� I P 1\
-I✓ AdL
STREET �� t.DDRZSS C STATE. AT;
f® P e. I Ue, 1"'-�e> CA.
9 S G
CONT. C -ME /
E ?vLALr
CQ
ST "ET a. t- iF% � � �/ 3 /� .� C`TYj(S .4Tr',, p '��' �? � �� / `l'I x `6\ C
ovm R ❑ ov'w--P -3UII� m ❑ 'Oti1211M AGET*T
❑ COI\TPACTORAGM, T ❑ A_RCr:iiECT ❑ F–NGD=\ —P, ❑ DEVELOPER ❑ icNihT
CONT a TO�A.I �f t�� I T.IC�,?,'S" � ''"d'! J � / I LIC�SE i1 BUS. LIC .' J , --k -
CON;��YN�.I���."-i� E.N1�v -
S TF -T ?)DRES� d; J C .r ATZ,: �
Cer G,
FAX CX
2
ARCETECT/ENG>?�'EER NAME LICENSE NUMBER (
---•--- - '—'
BUS. LIC--,,' M,�4
COI,/iPA1v'YK"I�iF,
i t.-I�1II. — _—.—
FAX
STREET .ADDRESS
CITY, STATE_7-11P
I PHONE
USE OF ❑SFJ or DUPLFY L7 ?vIULTI-r:Sh�.Y I . PROIEC'C LN V'II'DLELNIi7 ❑ YES
BUU.DL\1G:_ ❑ Como-aacl4-T �u T)TIPAN. LN=,. ACE/i'-Ek ❑ Np
P320inCT LSI ❑YES
� FLOOD ZONE ❑ NO
IS . BLDG .tiTI
� EICHLER!'iOME? E] No
TOTAL VAI"UATION:
By mysignature below, I certify to each of oliowin : I 1 the property owner or authorized agent to act on the. operty o;; ner's behalf. I have read tlu
application and the infor?na�' I have pr ded is corn t 'ave- e Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws re *' rQ to b _ dinor ct' I 1 ' 0 ' pr sentatives of Cupertino to enter the above-ide + 'fed y purposes.
for inspection puoses.
Si°nature afApplicaat/Agent: Date: 'S
PPLE]��EI� .t AL L\TFORMATION REOUIP.ED
MEPMiSCXpp_2011. doc revised 06/?1/11
CITY OFUPERTINO
FEE ESTIMATOR CBUILDI G DIVISION 15 100 9-0
ADDRESS: 10294 Dempster Ave
FEE ID
DATE: 10/15/2015
REVIEWED BY: PAUL
APN: 326 47 072
Ila
BP#:
Elee. Permit Fee: IEPERMIT
*VALUATION: $950
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
$48
PENTAMATION 1 REAP1
PERMIT TYPE:
WORK
Install 2 N 15 Amp Circuits in 2 Bathrooms for 2 New Washlets
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
l'Irwib. flan Check c'k
QTY
UNITS
BP FEES
Elee. Permit Fee: IEPERMIT
Recep/Switch/Outlets
1 BREMRECEP
Other Elec. Insp. 0.0 hrs $48.00
2
#
$48
PME Unit Fee:
$48.00
PNM Permit Fee:
$48.00
( onsiruction Ta :
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? 0 Yes (•) No
$0.00
TOTALS:
Travel Documentation Fee: I TRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/13)
!Tarr ('heck
l'Irwib. flan Check c'k
Elec. Plan Check 0.0Thrs $0.00
Aleck, Per°r)-rit t e .
Plumb. Permit 1;'ee:
Elee. Permit Fee: IEPERMIT
Irap.
Other Plumb Irrsrr.
Other Elec. Insp. 0.0 hrs $48.00
Wech. hup. Fee:
I',`aullb. hisp. Fee:
L.if%'c. It sp, Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the preliminary information available and are only an estimate Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan C:'hc>c°I-FFee:
F I
d f C?f7T-1
PME Plan Check:
$0.00
PME Unit Fee:
$48.00
PNM Permit Fee:
$48.00
( onsiruction Ta :
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? 0 Yes (•) No
$0.00
AdvC nl,,---ed P1L:17tJ'Z7r✓g Fees.,
Travel Documentation Fee: I TRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
l Select an Administrative Item
�
Bldg Stds Commission .Fee: IBCBSC
$1.00
SUBTOTALS:
$190.50
$0.00 TOTAL FEE:
Revised10/01 /2015
W