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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22577 SAN JUAN RD CONTRACTOR:EISENBACH PERMIT NO: 10100063
CONSTRUCTION
OWNER'S NAME: MICHAEL DHUEY 1130 CHERRYVIEW LN DATE ISSUED: 10/07/2010
OWNER'S PHONE: 4085053226 SAN JOSE,CA 95118 PHONE NO:(408)265-5925
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT .. PLUMB "
License Class %� 'fr Lic.4 'y/6 G 7
MECH RESIDENTIAL — COMMERCIAL
Contractor g#,j Date %el —-7— /CJ
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:BATH REMODEL NON-STRUCTURAL INCLUDE
(commencing with Section 7000)of Division 3 of the Business&Professions MECH/ELECT/PLMBNG
Code and that my license is in full force and effect. REPLACE WATER HEATER,ADD 220 VOLT CIRCUIT AT
I hereby affirm under penalty of perjury one of the following two declarations:
1 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,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$20000
permit is issued.
APPLICANT CERTIFICATION APN Number:34217084.00 Occupancy Type:
I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said C'
,>y in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicapAnderstands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point-source reg tuns er the ertino Municipal Code,Section
9.18.
Signature F' Date /a— 7—/c.) Issued by: Date:
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. if a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,l shall maintain compliance with the Cupe ino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Co J ons -05,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,l /A
become subject to the Worker's Compensation provisions of the Labor Code,I must O ner or. th rGfed age�.
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is l hereby affirm that there is a construction lending agency for the performance of work's
correct.l agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
ADDITION/REMODEL
CUPERTINO FEE SCHEDULE
APN# �L I� U Date:
. J % - -7 iu
Is a 2"d unit being added? Yes ❑ No If Yes, lease fill out the permit application for 2"d unit.
Building Address:
2 2S-7
Mailing Address (if different from building address):
Owner's Name: Phone #
X/rte
Contractor: I I
/ Phone#: ?'06 - c2,13 S7e?
4�517SeN' A 4 C�,� c, �, Fax#:
Cupertino Business License: State Contractor License #: 4,V,6 p 7:s
Contact: Phone#: y69 79
�aJ Fax#:
Landscape Ordinance Compliance:
Landscape area in sq. ft. (includes all irrigated areas):
If 2,500 sq. ft. or less, compliance with the Landscape Water-Efficiency Checklist is required.
If more than 2,500 sq. ft., a complete Landscape Project Submittal is required.
Compliance Method: ❑ Plant Type ❑ Water Budget
Building Permit Info:
Bldg. E Elect. Plumb. Mech. Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including addition)?
/N 4ok --1Ae y7/MAe17e,
Remodel Includes Re-Roof: Yes V �" zacE
❑ No � If yes list number of squares
Remodel Includes Structural: Yes ❑ No
Do you have the pre-application planning approval? Yes ❑ No
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath X41) O er
Type of Construction (Usage Class): Occupancy Type: L-
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B Valuation: 2 v ,cc.er .
Please check this box if the project is a
Project Size: Exp essEErStandard ❑ Large ❑ Major ❑ second-story addition ❑
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.
Revised 05/18/10
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: 2 2 S'7 5'p�/ ✓DIPJ / , PERMIT# 00
OWNER'S NAME: )I,- PHONE# y-0c01 .s'zur 322-111
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: G'2 4oreeS CITY/ZIPCODE: G/G a &4 5'SGz,a
*Our municipal code requires all businesses working in the city to have a City of Cupertino bilsiness license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS E OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V 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
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$20,000
xPERMIT TYPE: Building Permit I PLAN CHECK TYPE: Alteration / Repair
PRIMARY l'�)./�71� PENTAMATION �f�L
USE: SFD or Duplex F��OUR 4R/,,'A PERMIT TYPE: � A
WORK Bath remodel non-structural include M E P. Replace W/H add 220 Volt circuit at garage location.
SCOPE Field verify if upgrade to Electrical requires a load calculation.
Xfcch. Man Check Plumb.Plan Check 0.0 hrs $0.00 Elec. Plan Check 0.0 hrs $0.00
wiO). Permit Pee: Plumb.Permit Fee: IPPERMIT Elec.Permit Fee: IEPERMIT
Other Afech.Insp. Other Plumb Insp. 0.0 hrs $42.00 Other Elee.Insp. 0.0 hrs $42.00
1kch.Insp, Few: Plumb, hisp. Fee: E>lce.Insp. Fee.
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 09-051 E'. 7/l/l0) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 130 s.f. Remodel,Bath(<=300 sf)
Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 $570.00 IREMRESBAT
PME Plan Check: $0.00 0 # Plumbing
Permit Fee: $0.00 $25.00 1PRWHEATR Water Heater
Suppl. Insp. Feed Reg. 0 OT 0.0 hrs $0.00 0 Electrical
PME Unit Fee: $0.00 $42.00 IBREMRECEP Recep/Switch/Outlets
PME Permit Fee: $84.00 1 # Electrical
Construction Tax $126.00 IBREMMISC Conductors
Acoustical Fee: 0 Yes (F) No $0.00 0
Work Without Permit? 0 Yes (F) No $0.00
Planning Fee: $0.00 Select a Non-Residential Q
or Structure 0
Travel Documentation Fee: . ITRA VDOC $42.00 Building �
Strong Motion Fee: IBSEISMICR $2.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $129.00 $763.001 TOTAL FEE: 1 $892.00
Revised: 9/29/2010
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