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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11229 STAUFFER LN CONTRACTOR:AMERICAN KITCHEN& PERMIT NO: 10050200
BATH
OWNER'S NAME: WILLIAM LO 1758 JUNCTION AVE UNIT D DATE ISSUED:05/27/2010
OWNER'S PHONE: 4082066986 SAN JOSE,CA 95112 PHONE NO:(408)436-8151
I� LICENSED CONTRACTOR'S DECLARATION F r' f—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# X33 MECH RESIDENTIAL F COMMERCIAL r
Contractor A,raecgw Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMODEL BATHROOM(199SQF'f);NON-STRUCTURAL
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 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. Sq.Ft Floor Area: Valuation:$15500
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3 700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:36609050.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued b. . Date.J -2-z
9.18.
Signature Date 9-
RE-ROOFS:
I� OWNER-BUILDER DECLARATION 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
1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should l store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
[certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Ow} th 'zed ent
Compensation laws of California. If,after making this certificate of exemption,I Date -Ae
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this pennit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that 1 have read this application and state that the above information is Lender's Name
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 Lender's Address
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 ARCHITECT'S DECLARATION
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 regulations per the Cupertino Municipal Code,Section
9.18• Licensed Professional
Signature � Date �,,;L
.� CITY OF CUPERTINO
- ' ADDITION/REMODEL
CUPERTINO PERMIT APPLICATION FORM
APN #�5 o9
(0 5-� Date
Is a 2"d unit being added? Yes ❑ No,N If yes,please fill out the permit application for 2" unit.
Building Address:
1 29 S
Mailing Address (if different from building address):
Owner's Name: Phone# :
1 1ZJo1 <?o -0g
Contractor: -aY AAvS Phone k.%*rr) Y-36-91-F-1
Fax #: NB 3 g r-
Contractor License#: 513 939
Cupertino Business License#:
Contact: Phone #(",?) 934--f-Is/
E Fax #:
Building Permit Info:
Bldg. 0--' Elect. Plumb. ® Mech. Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including addition)?
'07;"APw'-A &-tooV s_r.4PLJd"A10
Remodel Includes Re-Roof. Yes ❑ No If yes list number of squares
Remodel Includes Structural: Yes ❑ No ®.
Do you have the pre-application planning approval? Yes ❑ No Z
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
/901
Remodel: Kitchen Bath - -- Other
Type of Construction (Usage Class): Occupancy Type: h
1•-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B S 6he "O:Arn.,4V 1 L
Valuation:01j;5;ae -- Please check this box if the project is a
second-story addition ❑
Project Size: Express ❑ Standard Large ❑ Major ❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set& the sheet index.
***For Office Use Only***
Over-the-Counter 0 Revised 07/06/09
CITY OF CUFERTINO
.aG ADDITION/REMODEL
CUPE�FINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
ADDITIONS 1R3SFl)ADD
1PLLONGRNGR Long Range PL
P lanning/Residential
1 R3INSP Dwellings Inspections B
1 R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1R3REPPLNC Dwellings Repeat Plan B
Check
1R3HINSP Dwellings Hillside B
inspection
1R3HPLNCK Dwellings Hillside plan B
check
1R3HREINSP Dwellings Hillside B
Repeat Inspection
1R3HREPLNC Dwellings Hillside B
Repeat Plan Check
1 R3ALTINSP Dwellings Alternate B
Materials Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check
1 PCESS Cesspool P
1 PPRSEWG Ea. Private Sewage P
Disposal System
1 PRSEWER Sewers P
1BPSPRINK Lawn Sprinkler/Backflow P
1BPWSVCS Main Water Service P
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
r 1BSEISMICRE SeismicResidential B
1REROOFRES Residential Re-roof Each B
100 SF
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RTI NO Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: / PERMIT# d O 2 O D
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: )r ffV
A,,, -i r CITY/ZIPCODE: ScT , S'iu
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALI SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors. S 2
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring /Carpeting
Linoleum /Wood
Glass /Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting /Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date