15090199 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11755 SEVEN SPRINGS PKWY CONTRACTOR:JS MILLER PERMIT NO: 15090199
CONSTRUCTION
OWNER'S NAME: YU CATHY C R TRUSTEE 21701 STEVENS CREEK BLVD STE 292 DATE ISSUED:09/29/2015
OWNER'S PHONE: CUPERTINO,CA 95014 PHONE NO:(408)446-1407
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
REMODEL BATHROOM(100 S.F.)AND KITCHEN(150 S.F.)
License Class Lia# -NO STRUCTURAL CHANGES
Contractor Date
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: Sq,Ft Floor Area: Valuation:$25000
1. 1 have and will maintain a certificate of consent to self-insure for Worker's
fnsation,as provided for by Section 3700 of the Labor Code,for the APN Number:36653024.00 Occupancy Type:
mance of the work for which this permit is issued.
and will maintain Worker's Compensation Insurance,as provided for by
3700 of the Labor Code,for the performance of the work for which this
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 FROM LAST CALLED INSP CT ON.
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 Issued by:0--i-Lo Date:
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 permi .Additionally,the applicant understands and will comply with
all non-poi iso e re ns per the C pertino Municipal Code,Secti n 9.18. RE-ROOFS:
�y All roofs shall be inspected prior to any roofing material being installed.If a roof is
Signature N Date [ installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ ER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the
2. I,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(x)should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
1. I 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 I 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 Code,Sections 25505,25533,and 25534.
2. I have and will maintain Worker's Compensation Insurance,as provided for by Owners a„utho ' d ages It
G
Section 3700 of the Labor Code,for the performance of the work for which this Date• A-1-2 CA�
permit is issued.
s. I certify that in the performance of the work for which this permit is issued,I shall ONSTRUCTION LENDING AGENCY
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 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.)
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 11755 Seven Springs Pkwy DATE: 09/29/2015 REVIEWED BY: PAUL
APN: 366 53 024 BP#: *VALUATION: $25,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex
_F PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK Remodel Bathroom 100 S.f. and Kitchen 150 S.f. - No structural changes
SCOPE -
'k,ch. plan CI her::h.I'r ur C'hed Elec. £'frit ('hack
ph En:.. f'<., t Fee: 1>lt c r'eMrnir
Ch?rer Alech.h. Tns;�. 01 er r'la m't iYt.P. Other I,Ic c lisp
ED--L-
P/YoO. h til). Fee: Ele'c.jpsS:l,r''ee;.
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc . Thesefees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l in o.
FEE ITEMS�Tce Resolution 11-053 E . 711.113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 100 s.f. Remodel,Bath(<=300 sf)
Suppl.PC Fee: (j) Reg. 0 OT 0.0 I hrs $0.00 $645.00 IREMRESBAT
PME Plan Check: $0.00 150 s.£ Remodel,Kitchen(<=300 sf)
Permit Fee: $0.00 $645.00 1 IREMRESKIT
Suppl. Insp.Feer Reg. 0 OT0 0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative Pee: 0
Work Without Permit? 0 Yes (j) No $0.00 E
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Building or Structure
Strong Motion Fee: IBSEISMICR $3.25 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC ', $1.00
SUBTQTALS ` $4.25 $1,290.00 TOTAL FSE"" $1,294.25
Revised: 07/02/2015