15070210CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 15070210
19161 LOREE AVE CUPERTINO CA 95014 (375 07 03 1)
OWNER/BUILDER
OWNER'S NAME:
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER/BUILDER Date
—BLDG —ELECT —PLUMB
MECH RESIDENTIAL COMMERCIAL `
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.
JOB DESCRIPTION:
ADD 342 S.F. TO ENLARGE (E) BDRM & ADD (N)
I hereby affirm under penalty of perjury one of the following two declarations:
BEDROOM, ADD 2 (N) COVERED PORCHES (95 S.F.).
1. 1 have and will maintain a certificate of consent to self -insure for Worker's
REMODEL (E) KITCHEN 149 S.F., REPLACE 5 (E)
Compensation, as provided for by Section 3700 of the Labor Code, for the
WINDOWS, REPLACE/RELOCATE (E) FURNACE
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
Sq. Ft Floor Area:
Valuation: $120000.00
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
375 07 031
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
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST C ECTION.
Signature Date 05/05/2016
Issued by: M ' N '
Date: 05/05/2016
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
_ compensation, will do the work, and the structure is not intended or offered for
inspection.
s le (Sec.7044, Business & Professions Code)
1' as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 05/05/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under Chapter 6.95 of the
a Section 3700 of the Labor Code, for the peffolmance of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
ermit is issued.
certify that in the performance of the work for which this permit is issued, I
Health &Safety Code, Section 25532(a) should I store or handle hazardous
1'
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chhpter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 2553A and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 05/05/2016
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all noon -point source regulations per the Cupertino Municipal
1 understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature ` Date 0510512016
Professional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION I` o
ADDRESS: 19161 LOREE AVE
DATE: 07/29/2015
REVIEWED BY: MELISSA
APN: 375 07 031
BP#:
*VALUATION: $120,000 Lj
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
2nd Unit? 0 Yes != No
PENTAMATION 1 R3SFDADD
I
USE:
$0.00
OTC? 0 Yes E) No
PERMIT TYPE:
WORK
ADD 342S.F. TO ENLARGE
E BDRM & ADD N BEDROOM ADD 2 N COVERED PORCHES 95
SCOPE
S.F.). REMODEL (E) KITCHEN 149 S.F., REPLACE 5 (E) WINDOWS, REPLACE/RELOCATE (E) 0
Mech. Plan Check 10.0 1 hrs $0.00 Phonb. Plan Cheek glee. Plan (.heck
Mech. Permit Fee: IMPERMIT Plumb. Pei -mit Fee: I Cec. Per~writ 1%ee:
Other Mech. Insp. 0.0 hrs $48.00 (31{aet I'lutrzh .Crr.s ,El
Other Elea Ir-sp.
Alcech. Ir yps Fee: Phimb. Ins. Fee: Elea Insp. Fee:
rVnTF• Thio ncfirnnfn dna. unf i»nlvdo 'foot dreo in nfhar Danartrnontc /i o Phmnin4_ Puhlir Warkv- FZYP_ Nonitarv.V~r District. School
Ilicfrint afp ► Thoca foac nra hacod nn tho nroliminary infnrmatinn availahle and are nnly an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/f 1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$1,626.00
149 s.f. Remodel, Kitchen (<=300 sf)
IREMRESKIT
$645.00I ,
Suppl. PC Fee: � Reg. 0 OTFo-,
0
hrs
$0.00
PME Plan Check:
$0.00
1
$143.00 1
Mechanical
FR=<100 Furnace, Forced -Air
Permit Fee:
$1,323.00
Suppl. Insp. Fee -.0 Reg. 0
OT
0,0
hrs
$0.00
Window / Sliding Glass Door
$431.00 1 WINREP Replacement
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
Construction T,=dminisli'fi1h;
e Fee
O
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee:
1PLLONGR
$61.18
Select a Non -Residential
Building or Structure
OA
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee:
IBSEISMICR
$15.60
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$5.00
_ p
Em S!CBTOAL
$3,126.78
$1,219.004'
$4,345.78
Revised: 07/02/2015