13070173CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21830 LOMITA AVE
CONTRACTOR: HQY CONSTRUCTION CORP
PERMIT NO: 13070173
OWNER'S NAME:
66 21ST AVE
DATE ISSUED: 09/05/2013
OWNER'S PHONE:
SAN MATEO, CA 94403
PHONE NO: (650) 288-8190
❑ LICENSED CONTRACTOR'S DECLARATION
r— I— F
BUILDING PERMIT INFO:
BLDG (ELECT PLUMB
License Class_ Lic. #
MECH F RESIDENTIAL F
COMMERCIAL
Contractor Ow c "Date 1 20
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION:CONSTRUCT ONE STORY ADDITION (283 SQ FT);
(commencing with Section 7000) of Division 3 of the Business & Professions
INTERIOR REMODEL (140 SQ FT).
Code and that my license is in full force and effect.
11/20/13 - REV # 1 - RELOCATE & REPLACE (E) WATER HEATER & ADD I
I hereby affirm under penalty of perjury one of the following two declarations:
OUTLET (GFCI), UPGRADE PANEL TO 200 AMP & MOVE & REDUCE
i. I have and will maintain a certificate of consent to self -insure for Worker's 1
BATH M WINDOW IN SIZE-ISSD OTC 11/21/2013
Compensation, as provided for by Section 3700 of the Labor Cod I
performance of the work for which this permit is issued.
2. '1 have and will maintain Worker's Compensation Insurance, ed f
Section 3700 of the Labor Code, for the performance of the 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 Municipal Code, Section 9.18.
Signature Date l ( 20 ( -5
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. I, 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)
2. I, 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:
t. 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.
2. 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.
3. 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.
Signature Date.
Sq. Ft Floor Area:
APN Number: 35715007.00
Valuation: $40000
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAA FROM LAST CALLED INSPECTION,
Issued by:
Date// 2,C ID
RE -ROOFS:
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.
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(x) 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: Date:
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 Professiona
CITY OF CUPERTINO
IM -E FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
21830 LOMITA AVE
DATE: 11/20/2013
REVIEWED BY: MELISSA
Xlech. Permit Fee:
APN: 35715 007
BP#: 13070173
*VALUATION: Iso
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
USE: SFD or Duplex
Plumb. hisp. Fee:
PENTAMATION
PERMIT TYPE: PRWHEATR
WORK
REV # 1 - RELOCATE & REPLACE E WATER HEATER & ADD 1 OUTLET GFCI UPGRADE
SCOPE
PANEL TO 200 AMP & MOVE & REDUCE BATHROOM WINDOW IN SIZE
I
t
rbfech. flan Check
Plumb. Plan Check 0.0 hrs $0.00
Elec. Plan Check 0.0 hrs $0.00
Xlech. Permit Fee:
.\
Elec. Permit Fee: IEPERMIT
Other Mech. Insp,
Other Plumb Insp. 12.Oj hrs L$47.00
Other Elec. Insp. H hrs $47.00
1,1ech. Insp..Fee:
Plumb. hisp. Fee:
Elec. Insp. Fee:
Suppl: PC Fee: (j) Reg. 0 OT
0.0
hrs
i
PME Plan Check:
$0.00
F-2-0-07 amps
$47.00
Electrical
IBELEC200
Services
s
$0.00
Suppl. Insp. Fee.S Reg. OT
0.0
hrs
$0.00
�� Electrical
$47.00 IBREMRECEP
Recep/Switch/Outlets
PME Unit Fee:
$0.00
PME Permit Fee:
$94.00
r
Consir action Tax:
Administrative Fee: IADMIN
$4 . 0
IV V
�r
Work Without Permit? O Yes O No
Z$0.00
Advanced Planning Fee:
I
t
rbfech. flan Check
Plumb. Plan Check 0.0 hrs $0.00
Elec. Plan Check 0.0 hrs $0.00
Xlech. Permit Fee:
Plumb. Permit Fee: IPPERMIT
Elec. Permit Fee: IEPERMIT
Other Mech. Insp,
Other Plumb Insp. 12.Oj hrs L$47.00
Other Elec. Insp. H hrs $47.00
1,1ech. Insp..Fee:
Plumb. hisp. Fee:
Elec. Insp. Fee:
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 based on the Preliminary information available and are only an estimate. Contact the Deptjor addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
1 #
$28.00
Plumbing
IPRWHEATR
Water Heater
Suppl: PC Fee: (j) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
F-2-0-07 amps
$47.00
Electrical
IBELEC200
Services
Permit Fee:
$0.00
Suppl. Insp. Fee.S Reg. OT
0.0
hrs
$0.00
�� Electrical
$47.00 IBREMRECEP
Recep/Switch/Outlets
PME Unit Fee:
$0.00
PME Permit Fee:
$94.00
Consir action Tax:
Administrative Fee: IADMIN
$4 . 0
IV V
Work Without Permit? O Yes O No
Z$0.00
Advanced Planning Fee:
$0.00
NV
Select a
Non -Residential
Building or Structure
0
Travel Documentation Fee: ITRAV oC
$47.00
Strom Motion Fee:
$0.00
Select
1
an Administrative Item
-z,(h.
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$185.00
$122.00
TOTAL FEE:
$3017.0
Revised: 10/01/2013
11
BUILDING ADDRESS: 21830 LOMITA AVE
CITY OF CUPERTINO BUILDING PERMIT
CONTRAVTno: TBG . __ I PERMIT NO: 13070173
I OWNER'S NAME: 11-1r. AI I DATE ISSUED: 09/05/2013 1
I OWNER'S PHONE: 1 , 1 PHONE NO:
N LICENSED CONTRACTOR'S DECLARATION
License Class S Lic. # % aq, c) p
Contractor 4, "l Date 2 20j
I hereby affirm that 1 4 I ensed under ti 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 Date
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, 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)
I, 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.
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.
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
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.
Signature Date.
JOB DESCRIPTION: RESIDENTIAL
CONSTRUCT ONE STORY ADDITION (283 SQ FT);
INTERIOR
REMODEL (140 SQ FT).
Sq. Ft Floor Area: I Valuation: $40000
APN Number: 35715007.00 E Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18 AYS OF PERMIT ISSUANCE OR
180 DAPS / LAST CALLEDINS�P CTI01�1<
Issued by: Date: /
RE -ROOFS:
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.
Signature of
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. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.112 and the
Health & Safety Code, Section 25532(a) should 1 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: Date:
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
ry
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21830 LOMITA AVE
CONTRACTOR: THOMAS WU
PERMIT NO: 13070173
OWNER'S NAME:
21830 LOMITA AVE
DATE ISSUED: 09/05/2013
OWNER'S PHONE:
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL0
License Class Lie. #
CONSTRUCT ONE STORY ADDITION (283 SQ FT),
INTERIOR
Contractor Date
REMODEL (140 SQ ET).
I hereby affirm that 1 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
Sq. Ft Floor Area:
Valuation: 540000
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
APN Number: 35715007.00
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
building construction, and hereby authorize representatives of this city to enter
WITHIN 1 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS R M LAST CALLED INSPECT ON.
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: Date:
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.
RE -ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
❑ OWNER -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
I, as owner of the property, or my employees with wages as their sole compensation,
wil I do 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
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
1 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 2 , _ 33, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
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, 1
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
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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. Addi 'a11y, the applicant understands and will comply
with all non -point soure ul ions per the Cupertino Municipal Code, Section
�
Licensed Professional
9.18. %
Date
Signature
CITY OF cCUFERTRNO
FEE ESTIMATOR — BUILDING DEWSRON
IalADDRESS: 21830 lomita ave DATE: 07/29/2013 REVIEWED BY: Mendez
N: BP#: 4 D 'VALUATION: 1$40,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD Or Duplex 2nd Unit? Yes o0 No PENTAMATION 'IR3SFDADD
USE: I OTC. Yes ONo PERMIT TYPE:
WORK ADD 283 SQ FT TO INCLUDE 1 BEDROOM ENLARGE KITCHEN AND 1 BATHROOM /
SCOPE CONVERT (E) BATHROOM TO LAUNDRY ROOM 140 sq ft, RELOCATING GAS METER addition ofF,
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.ff.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,111-B,IV,V-B
283
$1,579.00
IADDPLCK
$1,284.00
IADDINSP
Elec, Insp. Fee:
Suppl. Insp. Feer Reg. 0 OT 0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
I
Construction Tax: IF]
Administrative Fee:
0
0
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee: IPLLONGR
$39.62
TOTALS:
283
$1,579.00
Strong Motion Fee: IBSEISMICR
$1,284.00
Select an Administrative Item.'
MECH, HOURLY 0 Yes G No
PLUMB, HOURLY 0 Yes E) No
ELEC, HOURLY 0 Yes 0 No
Xlech. Plan Check
Phunb. Plan Check
Elec. Plan Check
hfech. Pennit Fee:
Plumb. Permit Fee:
Elec. Permit Fee:
Other ;'Meeh. Insp.Li
Other Plumb Insp.
Other Dec. Insp.
Alech. Insp. Fee:
Phtmb. Insp. Fee:
Elec, Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Dictrirt otr_ L Thoco foot aro hacod an tho nroliminary inlarmatinn availahlo and nro nnly an octimnto_ 1-a"tart tho (Dont far add" 11 infa_
FEE ITEMS (Fee Resolution 11-053 Eff. 711,1121
FEE
QTY/FEE
MRSC ITEMS
Plan Check Fee:
$1,579.00
140 s.f. Remodel, Other
$418.00 IREMRESOTH
Suppl. PC Fee: (F) Reg. Q OT 0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,284.00
Suppl. Insp. Feer Reg. 0 OT 0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
I
Construction Tax: IF]
Administrative Fee:
0
0
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee: IPLLONGR
$39.62
Select a Non -Residential 0
Building or Structure 0
G;
Travel Documentation Fees:
Strong Motion Fee: IBSEISMICR
$4.00
Select an Administrative Item.'
Bldg Stds Commission Fee: IBCBSC
$2.00
SUBTOTALS:
$2,908.62]1$418.00
TOTAL FEE: $3,326.62
Revised: 07/01/2013