12010143CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(d�cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION/ DEFERRED ORIGINAL PERMIT it
PROJECT ADDRESS �
APN #
3�`' -� r
OWNER NAME
ONE Z 3
E-MAIL
Ut
4 D
STREET ADDRESS �j/ r r
flLe-
CITY STATE. ZIP y.0I
FAX
�d. L
CONTACT NAME
PHONE ` — i
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STREET ADDRESS CITY, STATE, IIP
_
FAX
/, 4 � We Lt g�_
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It
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME T
l�
LICENSE NUMBER
F77SFTYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
a G C'zL� U3
FAAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
`
DESCRIPTION OF WORK `� , ,IL�J
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
I
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: U DETACH
❑ATTACH
# DWELLING UNITS:
IS A SECOND UNIT
BEING ADDED? O
SECOND STORY C]YES
ADDITION? []NO
Q
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY: ^
TOTAL VALUATION:,D
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER ROME? ❑ NO
J '
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
for inspection purposes.
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -i tified7F�
Signature of Applicant/Agent: Date: ( 'L t -.;t-
SUPPLEMnTALINFORMATIONREQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER -TETE -COUNTER
ET BurLDING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS '
-Q'F–LANNI NG PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
SARD
O'PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
C]--f/IRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
El MAJOR
0 SANTTARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
IG r
����CITY OF CUPERTINO
O
I —I I FEE ESTIMATOR — BUILDING DIVISION
ia0i 0143
& YA
ADDRESS: 20550 BLOSSOM LN
DATE: 01/23/2012
REVIEWED BY: SUEW
EMN
APN:
BP#:
*VALUATION:
Iso
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: New Construction
PRIMARY SFD or Duplex
USE:
•
2nd Unit? Yes No
PENTAMATION 1R3SFD2ND
PERMIT TYPE:
WORK
2ND UNIT 367 SQFT.
[ATTACHED
SCOPE
$0.00
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s1
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,111-B,IV.V-B
367
.00
IR3PLNCK
$ .00
IRMNSP
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,5 0
Suppl. Insp. Fee -0 Reg. Q OT
p 0
hrs
$0.00
PME Unit Fee:
TOTALS:
367
$2,4 .00
$19.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc )_ These fees are haled an the nreliminary information availahle and are only an estimate_ Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7;7-11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2 0.000=
#
$0.00
Foundation Repair
Suppl. PC Fee: E) Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,5 0
Suppl. Insp. Fee -0 Reg. Q OT
p 0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTA;R
0
# �,nene w
lliO
$0.00
Work Without Permit? 0 Yes (D No
$0.00
.Advanced Planning Fee: PLLONGRNGR
$47.1
Select a Non -Residential
Building or Structure
�
0
i
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00)
SUBTOTALS:
$ 6.71
$0.00
TOTAL FEE:
Revised: 1/19/2012
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