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15120022CITE' OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 833 COTTONWOOD DR CONTRACTOR: DOMITROWICH JOSEPH PERMIT NO: 15120022 R ET AL OWNER'S NAME: DOMITROWICH JOSEPH R ET AL 833 COTTONWOOD DR DATE ISSUED: 12/03/2015 OWNER'S PHONE: 4082551259 CUPERTINO, CA 95014-4621 PHONE NO: 171 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL F] License Class REPLACE 3 (E) WINDOWS (KITCHEN, MASTER BATH & Lie. # MASTER HALF. ADD S (N) RECESSED IN KITCHEN & Contractor Date REMODEL/RECONFIGURE (E) MASTER BATH (ADD SINK) I hereby affirm that I am licensed under the provisions of Chapter 9 so (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 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, Sq. Ft Floor Area: Valuation: $50000 as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 36917033.00 Occupancy Type: 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 PERMIT EXPIREI�NOT STAIaTED to building construction, and hereby authorize representatives of this city to enter WIT AYS OF PETE ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, I�LLED INSPECTION. judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will c y Issue _�,-sem Date: 3 d� with all non-point source regulations per the Cupertino Municipal Co e, Section 9.18. SignatureRE-ROOFS: Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for OWNER-BUILDER DECLARATION inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER will do the work, and the structure is not intended or offered for sale (Sec.7044, r 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 I hereby affirm under penalty of perjury one of the following three Health & Safety Code, Sections 25505, 25533, and 25534. I will declarations: maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 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 Compensation, as provided for by Section 3700 of the Labor Code, for the material. Additionally, should I use equipment or devices which emit hazardous performance of the work for which this permit is issued. 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 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 this the Health & Safety Code, Sectio s12 ra05, 25533and 255 4. which permit is issued. Owner or authorized agent: ;�%%F y/�'' "rDate:/, �I certify that in the performance of the work for which this is issued, I ,;% `%7!� � permit shall ot 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 I certify that I have read this application and state that the above information is Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source egulations per the Cupertino Municipal Code, Section 9.18. /, Licensed Professional %%/ Signature Date :' 2 - --- -- CONSTRUCTION PERMIT APPLICATION COM10UNI T Y DEVELOPP,liENT DEPAR T Mi�ENT a BUILDING DIVISION r 10300 T ORRE AVENUE a CUPERTINO, CA 85014-3255 ts CUPERT[hi0' (�' 08) 777-3228 FAX (4D8) 777-3333 buildino(a�cuDerino.orQ _5 Z_ 2 ❑ NEW CONSTRUCTION ❑ ADDITION ❑ .=L i P_kTION / TI ❑ REVISION / DEFERRED ORIGI ? A tp ER ,TI' J'41 0 '171L STREF1 ADDRESS`� uy,STATE, ZIP �_ - C`A STREET ADDRESS P TATE Zip El owI,LR ❑. ❑ okNAc=„-r ❑ co>,acroR ❑col.ILcroRa.c_I.-r rracr_-.R ❑ D��LOP ❑ CONiRACi0RI;hI✓r 9`� • I LICT'SENu%/L?ER I LICTT5_ 1yr-E Y I BUS. UC m bole1<Y hAO,tr-r-. F-N9IL FAX STREET ADDRESS I CITY, STAT -r-, ZIP PHONE ARC TiECTFri N0N:EI NAW:E I LICE\Sb h?.A SER BU'S. LIC m COl✓tPA1v'Y NA.1.:E .- - � - I E-1✓..<sL ' FAx STREET A.DDRIESS I CITY, STA -1-E, ZIP PHO11TE DESCP.ip7701.T OF WORK �� v 'A�%MfedI ��.� , eial nA¢.�,F'��t''rV /.`-' 1 ✓.gF j . r.Gs ��"a. F ^.' °•'° .� 6 l.. I''- ""� a - �n .v is �.,. ,-✓';Y j ew'<. _�Ar/ ra...-fi"r� J'�y y ;��a' E:aSTL>\G USE I PROPOSED USe I CON. STR TYNE ` I 4 STORr-PS - f 'USEC (- ?\'�ViZ.00R , E TYPEI OCC. 5Q•FT. I VyZUAT]Ol� (E) DEAto I TOTAL AREA AP.EA A_TtEh NET AREA BA i rR00M_T u i CION OTrMR RcIvIODELc�-A FEA4ODELAREh REM, ODELAIREA PORCH k%7 --A DECK AREA I TOT.:L. D�-cKnna ru T a e ri , r_ L] ATTACH 4 DtiLL�C U?\ii5: IS A SECOND UNIT ❑ YPS SECOND STORY EJ)SS _ BEING ADDED? ❑ :O ADDMON?(�?\-O I I I P?E, PLICATiO?� ❑ YES 1F YS, PRO iDE COPY OF IS TI E BLDG AN i PLA1.NM\'GAPPLR ❑NO PL A?\7\�GP.PPROVhLL_iIER LE ^o - _ _ - SI -� TOT.�L\%."LU.9� 0 ® V C/ By my signature below, I c_— iy to each of' he fel lowing: I am the Property o;;Iner r authoriL o a e propeirty owner's behal I hFve read this - application the information and I-have.provided is co„ect: I have read he Description of -Work and veri It inaccurate, -lag ee to comply with all applicable ]0 41 ordirar,ces and state laws re]ating -t td' /onstn� on. I aut arize represent_ti;°eS'of Cupertino to enter the above-identi-:-'e propery io�_pe_-tion g or SigmatOeofnDDllcant/Aggent: ,a/,ifs-/,!' - L .. .. .p. De purposes, SUPPLEI` RIaT ON REQUIRED - �' � w FD or �1L_LI_�m d. l;nc- _-- _ALT -y 1 �o, dcno 1 i ti o � —_ P Y a DeI--1_t :or _- --= - -- -- - -- - - - - ei bLi ;;,Q T` ; _ .� IC. _=(S), Je._101_t10I1 %alt IS .BdlluCCl r10 ;cs , Pe p r t0 _ U�'1Ce Ol` bL11d1.-1P -- - - - - - - - - - _ _ ;3 rco%r�R `T =J•__ - _-_-- -- - _BLTII31L�GTL_3 R,12r3�Y- tL_.rt for new bLl-din r I Bides: Pro; _de a c 1 I-; �, '„ �.. o�_�o.eted __�...zrd ?; �., ; 1, o_s.__terialsD.sc.�� - _ire - --=-- `� -- 1_�Z I'i2Zcrdour I1C'�^ Z_J are �.lIla used as part e=- - i �-'t_ s:•r====—_= _=- -- -- ---- _-_=`�'-�_�� - _ __ _ _ . _�� =�_ �=�= ---_ - Copy of Plu-Lnin,g Approval Leer or_M'eetirg with Planu-IL-1g prior to .!. submittal OI Building Petit application. F'� T L4TOR x - RaWt g, nge L - doc revised 06/21/11 CITE' OF CUPERTINO M'v FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 833 COTTONWOOD DR FEE DATE: 12/03/2015 REVIEWED BY: MELISSA APN: 369 17 033 BP#: €3 %f 't" .rt,`;. _ `r• *VALUATION: 1$50,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or DuplexLl USE: Q.p PENTAMATION 1 R3SFDREM � PERMIT TYPE: WORD REPLACE 3 E WINDOWS KITCHEN MASTER BATH & MASTER HALL. ADD 8 N RECESSED IN SCOPE KITCHEN & REMODEL/RECONFIGURE (E) MASTER BATH (ADD SINK)•80 S.F. 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 Dreliminary information available and are only an estimate. Contact the DeDt for addn'l info. FEE ITEMS (Fee Resolution 1.1-053 Ef. 7i1113, FEE QTY/FEE Elec. Plan CheckFO.0Fhrs $0.00 .'} .°. "f.'!.% ;' wit:r?'': " Elec. Permit Fee: IEPERMIT €3 %f 't" .rt,`;. _ `r• irr;, , /'ii1 ar-; _';:: Other Elec. Insp. 0.0 hrs $48.00 Suppl. PC Fee: (® Reg. 0 OT Q.p 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 Dreliminary information available and are only an estimate. Contact the DeDt for addn'l info. FEE ITEMS (Fee Resolution 1.1-053 Ef. 7i1113, FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 =s.f. $645.00 Remodel, Bath (<=300 sf) IREMRESBAT Suppl. PC Fee: (® Reg. 0 OT Q.p hrs $0.00 PME Plan Check: $0.00 [= # $431.00 Window / Sliding Glass Door IWINREP Replacement Permit Fee: $0.00 Suppl. Insp. Fee:(F) Reg. C) OT Q,0 hrs $0.00 ® Electrical $72.00 1BREMFIXT Fixtures, Lighting PME Unit Fee: $0.00 PME Permit Fee: $48.00 Administrative Fee: JADMIN $45.00 0 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee.- $0.00 Select a Non -Residential Building or Structure 0 i Travel Documentation Fee: 1TRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $6.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS-:, $149.50 $1,148.00 TOTAL EEE . $1,297.50 Revised: 10/01/2015