15020149M
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10300 VICKSBURG DR
CONTRACTOR:_TBD_- TO BE
PERMIT NO: 15020149
OWNER'S NAME: TANABE THOMAS M AND JOANNE
r
DATE ISSUED: 02/26/2015
OWNER'S PHONE: 6505690843
PHONE NO:
13 LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL F1 COMMERCIAL F1
a r�
REMODEL (E) KITCHEN (300 SQ FT); BATHROOM (45SQ
License Class Lic. # q 7q
FT) INTERIOR THROUGH OUT (505 SQ FT), 200 AMP
PANEL UPGRADE, TO INCLUE M,E,P'S
Contractor
I hereby affirdtha't I avillicensed 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
Sq. Ft Floor Area:
Valuation: $60000
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: 36914008.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IFYIOR IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAY-S-OF PE IT 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 FR ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses may accrue against said City in consequence of the
granting of this pe ionally, the applicant understands and will comply
Issued by: Date s
with all non-poi ulations per the Cupertino Municipal Code, Section
RE-ROOFS:
9.18.
Signature-
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.
4//
0 0 NER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 (See.7044,
Business & Professions Code)
1, 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. 1 will
I 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(a) 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 a Area Air Quality Management District I
by he Area
performance of the work for which this permit is issued.
will maintain compliance with t no Municipal Code, Chapter 9.12 and
' "'
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, S�ec 25533, and 25534.
5,
Section 3700 of the Labor Code, for the performance of the work for which this
Owner -26
Date:—?--15
permit is issued,
or authorized agent:
I 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
CONS RUCTION 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 (See. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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,
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
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building9cupe!1ino,om
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PROJECT ADDRESS
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STREET ADDRESS
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CONTACT NAME
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OWNER OWNTER-BUILDER OWNER AGEN -r IICONTRACTOR _11CONTRA.CTOR AGENT - []ARCHITECT PFNGINEER. 13DEVELOPER El TENANT
CONTRACTORNAMEJ,
LICENSE NUM
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LICE Ali TYPE
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COMPANY NAME
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
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COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
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10�\k. 011-OS :L
EXISTING USE
PROPOSED USE CONSTR. TYPE
I STORIES
111i
USE
/PE'
Occ.
SQFT.
VALUATION
FXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN OTHER
4)k-
REMODEL AREA
REMODEL AREA REMODEL
AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: In—DETACH
nATTACH
I
9 DWELLING UNTES:
IS A SECOND UNIT ❑ YES SECOND
STORY MYES
BEING ADDED? E]NO
ADDITION? [3NO
PRE-APPLICATION rl IF YES YES, PROVIDE COPY OF IS
THE BLDG AN [] -ITS
TOTAL IALUATION:
�
PLAN'NING APPL 9 E) NO PLANNING VAL LETTER
EICHLER HOME? [3 NO
certify
By my signature below, I certify t e the following: I am the property owner or authorized agent to aciie property owner's behalf. I have read this
... is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
application and the information
ordinances and state laws relati g t mg construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
;
'2 2
Si ;nature of Applicant/Agent: Date:
SUPPLEMENTIhNFORMATION REQUIRED
New SFD or Multifamily wellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance Of building
�R
permit for new building,
Jt"�'Ihj
Commercial Bldgs- Provide a completed Hazardous Materials Disclosure
�,wg
Torm if any Hazardous Materials are being used as part ofthis project.
Copy of Planning Approval Letter or Meeting with Planning prior to
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op,
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submittal of Building Permit application.
g 'g. g ig C
BldgApp_201 1. doc revised 06121111
Plan ( heck 1'himb' 11/�w C hceh Elea Plan Check e.0 hrs $0.00
Iec' =. 1 er,ariP r; , : pl, -i>. Permit Fei " Elec. Prmit Fee: 1EPERMu
tl s'aer,i c:cYr. I> s�. C,:heP Plurfti 1 , ,. Other Elec. Insp. 0.0 hrs $4$.00
:i ecd7. jnspJ Fee Plie137t7. hiv). Fee : IJ2sp,
NOTE. This estimate does not include fees due to other Departments (i.a Planning, Public Works, .faire, Sanitary Sewer District, School
District, etc . These Lees are based on the refimina information available and are onl an estimate; Contact the De t or addn'l info.
FEE ITEMS (free Resolution 11 -053 X7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
45 s.f. Remodel, Bath (< =300 sf)
$645.00 IREMRESBAT
Suppl. PC Fee: E) Reg. 0 OT
LEI
hrs
$0.00
PME Plan Check:
$0.00
300 s.f. Remodel, Kitchen (< =300 sf)
$645.00 IREMRESKIT
Permit Fee:
$0.00
Suppl. Insp. Fee.S Reg, 0 OT
0 01
hrs
$0.00
= s.f. Remodel, Other
$503.00 IREMRESOTx
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
200 amps Electrical
$48.00 IBELECZ4(t Services
C'onsirucfion Kn,
Administrative Fee: IADMIN
$45.00
0
E)
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning j�e
$0.00
Select a Non - Residential l)
1 Building or Structure 0
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: IBSEISMICR
$7.80
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$3.00
SUBTOTAL&
$151.80
$1,841.00 TOTAL F � 1
$1,992.80
Revised: 02114/2015