15100175-DP21941 COLUMBUS AVE
15100175
F/P
CHOW MAROLYN O TRUSTEE
SCANNED BOX # 688
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21941 COLUM 3US AVE CONTRACTOR: SUMMIT REMODELING I PERMIT NO: 15100175
OWNER'S NAME: CHOW MAROLYN O TRUSTEE 1381 E MCGLINCY LN I DATE ISSUED: 10/21/2015 I
OWNER'S PHONE: 4082577883
S ■ LICENSED CONTRACTOR'S DECLARATION
Lltls }las/j _f7L� 3� f f�—!5 f
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.
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.
2OPhave and will maintain Worker's Compensation Insurance, as provided for by
rr,t)l;ection 3700 of the Labor Code, for the performance of the work for which this
V 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 applicant understands and will comply with
all non -point rAegulati ons per the Cupertino Municipal Code, Section 9.18.
Datea �.
❑ 4 OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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:
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.
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.
a. 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, h6rmless'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
CAMPBELL, CA 95008 I PHONE NO: (408)377-5252
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
KITCHEN REMODEL; REMOVE WALL AT FAMILY ROOM;
MODIFY (E) SKYLIGHT SHAFT; REPLACE EXTERIOR DOOR;
INSTALL POCKET DOOR.
Sq. Ft Floor Area: I Valuation: $50000
APN Number: 35614035.00 I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FR LAST CALLED INSPECTION. t
Issued by: Date: t01
2—l
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 &jSafety Code, Sections 25505, 25533, and 25534.
Ow r autl ized agent• I
L S
ONSTRUCTION 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
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building0cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION
❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROTECT ADDRESS
APN #
OWNERNAME
Gl�t�
PHOJb6
E MAII
a� L %�
`—,757'
STREET ADDRESS ^
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CrrY, STATE, ZIP
LA (75'O /
FAX
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CONTACT NAME^
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PHONE
D - �Q —078 I
E-MAIL
STREET ADDRESS
CrfY TATE, ZIP
FAX
�C_1,,,. LIU
00
8- 77-l-7-1
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT 1�CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE E
BUS. LIC # `
COMPANY N
E-MAIL
FAX
377
STREET ADDRESS
�'G
CTTY TATE,ZIP
1� C 00
PHO
-&77- 2 Z
ARCHrTECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
1
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i
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(�. A� G�c��_C,c9f
vLcsII, Q t,7t r
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM KITCHEN
OTHER
REMODEL AREA REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
[]ATTACH
# DWELLING UNITS:
IS A SECOND UNIT OYES
SECOND STORY []YES
BEING ADDED? RNO
ADDITION? rjQNo
t�
PRE -APPLICATION El YES IF YES, PROVIDE COPY OF
PLANNING APPL # KN,O PLANNING APPROVAL LETTER
IS THE BLDG AN
EICHLER HOME?
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,'% .� ti
z
TOTAL VALUATION:
�+Cj•� �M `
By my signature below, I certify to each of the following: I am the property owner or autho ' d on the property owner's behalf. I have read this
application and the information I have pro vi s correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
uildi g s ction. I authorize representatives of Cupertino to enter the abo/ye-identified property for inspection purposes.
s ordinances and state lawrelating to build.,
Signature of Applicant/Agent: Date: L 0 �` 7
SUPPLEMENTAL INFORMATION R(2AED
u„PLAI`I`GYiECKTXPE„
.,ta`£ RotiTnNGsiiP,
❑gVER THE CovNTERuILDINGPLAN
REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
§
r
for building.
4
❑
permit new
EXPREss r�
PLANNING PLAN REVIEWty
'
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
�� STANDARII
❑ euBLIC woxKs
To—rm. if any Hazardous Materials are being used as part of this project.
t z f 1va
iARGE
,
❑ADEPT f s
_ Copy of Planning Approval Letter or Meeting with Planning prior to
}
MAaoR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
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❑ :ENVIR0114TENTALHEALTH"
B1dg,4pp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21941 Columbus Ave
DATE: 10/21/2015
REVIEWED BY: Phuong
APN: 356-14-035
BP#:
*VALUATION:
$50,000
PERMIT TYPE: Minor Building Permit
PLAN CHECK TYPE: Remodel, Kitchen (300 s.f. max)
PRIMARY Residential
PENTAMATION 1 R3SFDREM
USE:
PERMIT TYPE: A
WORK
Kitchen remodel; Remove wall at family room; modify a skylight shaft, Replace exterior door; Install
SCOPE
pocket door.
FEE ID FLR AREA
s.f.
1 REMRESKIT 250
r r •
e r e
A,Jech. Plan Check
Plumb. Plan C:l:eck
Elee. Plan Check
Meck Permit Fee:
[Plumb. Permit Fee:
Elec. Permit Fee:
Other Afech..Irasp.ET-L-
Other Plumb .bqp.
Other Elec. Insp.
Alech. Insp. Fee:
Plumb. Insp. Fee:
Elea Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution ]1-053 Ef 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
'A
Suppl. PC Fee
Plum b./Mech./Elec
Permit Fee:
$645.00
Suppl..Insp Fee
Plumb./Mech./Elec
Plumb.lillkch./Elec Permit Fee:
Construction Tax:
Aclministratire Fee:
Work Without Permit? O Yes (E) No
$0.00
Advanced .Planting Fees:
Travel Documentation Fees:
Stroniz Motion Fee:
IBSEISMICR
$6.50
1.0 hrs
$143.00 ISTINSP
Inspections
Inspection, Hourly
Bldg Stds Commission Fee: 1BCBSC
$2.00
SUBTOTALS:,..
$653.50
$143.00
TOTAL FEE:
$796.50
Revised: 10/01 /2015