15110167CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1081 MILKY WAY
CONTRACTOR: BLALACK JENNIFER M
PERMIT NO: 15110167
AND RUSSELL
OWNER'S NAME:
CUPERTINO, CA 95014 -5008
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
CONVERT SUNROOM TO HABITABLE SPACE - (N)
License Class Lie. #
FAMILY
ROOM AND BEDROOM (367.5 SF)
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.
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
Sq. Ft Floor Area:
Valuation: $20000
performance of the work for which this permit is issued.
1 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
APN Number: 36219001.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: ��%/� %�L Date:
granting of this permit. Additionally, the applicant understands and will comply
L /
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE- ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. Ira roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER- BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
Ilowing two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
wrier of the property, or my employees with wages as their sole compensation,
E
l o the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(x) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self- insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal-Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 22 5505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
21
p mit is issued.
Owner or authorized agent: Date:
ify that in the performance of the work for which this permit is issued, I shall
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
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
1 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 acid 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,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date a
CITY OF CUPERTINO
FFF ESTIMATOR — BUILDING DIVISION
imADDRESS:
1081 Milky Way
DATE: 11/23/2015
REVIEWED BY: Phuong
APN: 36219 001
BP #:
'VALUATION: 1$20,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
0.0
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
Convert sunroom to habitable space - N familv room and bedroom 367.5 SF
SCOPE
t;;'ec. i "'O r C,:'lec�
:.
.r
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0.00
t(ecil. Tian Cara:: ^ic
Suppl. PC Fee: Q Reg. Q OT
0.0
1'mii (,'heck:
$0.00
PME Plan Check:
t;;'ec. i "'O r C,:'lec�
Permit Fee:
$0.00
Suppl. Insp. Fee-0 Reg. Q OT
0.0
1 hrs
$0.00
lie ", I etf'Ji. >dll� ='ra.
f.11hc'i'
PME Permit Fee:
$0.00
(,'rmsirucli!; n I lx:
fel, <j .
LjCS`l2:.
19e,'1, iiS;J. 1't
1'1 : ?,rs1.
bt�p' Fee,
Advanced Planning Fee:
(.,.Pr,. 1- *'. P-C.
NOTE: This estimate does not include fees due to other Departments ('tie. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are hated on the nreliminary information availahle and are nnlv an ectimaty_ Contort the Dent for addn'1 infn_
FEE ITEMS (Fee Resolution 11- 053.Eff. 7/1/13,)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0.00
368 s. f. Remodel, Other
$503.00 IREMRESOTII
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee-0 Reg. Q OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
(,'rmsirucli!; n I lx:
..lrhnin slralive l 'ee:
Work Without Permit? Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
G
Q,
'1 "t•ui el 1.�rx:trt��i niarion Ft,? >s:
Strong Motion Fee: IBSEISMICR
$2.60
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS -1
$3.60
$503.00 TOTAL FEE
$506.60
Revised: 1010112015