15050057CITY OF CUPERTINO BUILDING PERMIT I
1 BUILDING ADDRESS: 21867 S14ATTUCK DR I CON TRUCT O : DIANLI CHEN I PERMIT NO: 15050057 I
OWNER'S NAME:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.# �� ( r a
Contractor nuo., iell co Date 1 1 04t
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:
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.
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
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 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
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
I*
10181 EMPIRE AVE I DATE ISSUED: 06/18/2015
CUPERTINO, CA 95014 1 PHONE NO: (408)888 -2898
JOB DESCRIPTION: RESIDENTIAL [] COMMERCIAL ❑
CONSTRUCT ONE STORY ADDITION (379 SQ FT);
REMODEL
DINING ROOM (125 SQ FT).
Sq. Ft Floor Area: I Valuation: $65000
APN Number: 35614003.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INS PECTION..
Issued by: �� /L �% G� Date: &- /6 .
v
f r1 `��� RE- ROOFS:
Date ✓ FJ C 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
inspection.
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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 sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
permit is issued.
1 certify that in the performance of the work for which this permit is issued, I shall
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
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 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
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.
Date
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: /11 i -:, �^ Date: l
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
T.
FMON CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
21867 SHATTUCK DR
DATE: 05/11/2015
REVIEWED BY: SEAN
PC FEE ID
APN:
BP #:
'VALUATION: 1$65,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE: P
2nd Unit? Yes No
OTC? 0 Yes ONO
PENTAMATION
PERMIT TYPE: 1 R3SFDADD
WORK
ONE STORY ADDI1 -ION 379 SQ FT).
[CONSTRUCT
SCOPE
Suppl. Insp. Fee-0 Reg. OT
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R -3 (Custom)
II- B,111- B,IV,V -B
379
$1,626.00
IADDPLCK
$1,323.00
IADDINSP
Permit Fee:
$1,323.00
Suppl. Insp. Fee-0 Reg. OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C Cii 4,1 i1'i?c. "lftif? f;'h ":
FT
0
E)
Work Without Permit? Yes Q No
$0.00
TOTALS:
379
$1,626.00
Z
$1,323.00
Stronp, Motion Fee: IBSEISMICR
MECH, H(? 0 Yes Q No
PLUMB, HOURLY Q Yes Q No
ELEC, HOURLY Q Yes Q No
MISC ITEMS
Plan Check Fee:
$1,626.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (E) Reg. () OT
FO.OThrs
El
$0.00
Li L_
$0.00
Permit Fee:
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the nreliminary information available and are only an estimate Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 E f' 7, U13)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$1,626.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (E) Reg. () OT
FO.OThrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,323.00
Suppl. Insp. Fee-0 Reg. OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C Cii 4,1 i1'i?c. "lftif? f;'h ":
FT
0
E)
Work Without Permit? Yes Q No
$0.00
Advanced Planning F, IPLLONGR
$53.06
Select a Non - Residential
Building or Structure
i
Z
Stronp, Motion Fee: IBSEISMICR
$8.45
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$3.00
I SUBTOTALS:'
$3,013.51
$0.00 TOTAL FEE:
$3,013.51
Revised: 04/01/2015