13120178 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21436 RUMFORD DR. CONTRACTOR:HOUSE 2 HOME DESIGN PERMIT NO:13120178
&BUILD
OWNER'S NAME: GOUDEY JOHN L AND CAROL A 254 TRUCKEE LANE DATE ISSUED:01/30/2014
OWNER'S PHONE: 4089967765 SAN JOSE,CA 95136 PHONE NO:(408)364-2231
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
RECONFIGURE&REMODEL MASTERBED,MSTRBTH&
License Class Lic.# UTILITY
ROOM(713 S.F.). UPDATE ELECTRICAL&REPLACE(3)
Contractor
Datei WINDOWS&DOORS IN REMODEL AREA(SHIFT UTILITY
I hereby affirm that I am licensed under the provisions of Chapter 9 RM
(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:
tl 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 Valuation:$212840
performance of the work for which this permit is issued. Sq.Ft Floor Area:
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:32641008.00 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 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 LED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
WITHIN 180 DAYS 0 IT 1
180 DAYS LED
costs,and expenses which may accrue against said City in consequence of the e
ssue te:
,granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9J8.
/1W
RE-ROOFS:
Signature_0 —Date 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.
11 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
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) HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,am exclusively contracting with licensed contractors to
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: 4 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 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 25505,25533,and 25534.
'Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: A�Date: /—'3 0 t y
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 CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall 6e 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 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.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.1&
Signature Date_
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 B
INO (408)777-3228-FAX(408)777-3333-building _cuDerling.orc
CUPERT
❑NEW CONSTRUCTION 0 ADDITION TERATION/Tl ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 2/�36 1Rumfor6 C) ive- _T APN 4 3 0
OWNER NAME - PHONE_, E-MAIL
0 6,7-16 Caro I ftao odau 5 c cmn
ZIP
CITY,
STREET ADDRESS 21,1316 Rbrnfo-ro cri vTATE e CuuLLnQ CA1
FAX
CONTACT NAME[Aaft Kc<-�,mussffl PHONE
STREET ADDRESSTE,ZIP FAX
2�A TAX-kee- LC(M, snse. C)a 96513& 1
0 OWNER eOWNER-BUILDER 0 OWNER AGENT 1-1 CONTRACTOR 11 CONTRACTOR AGENT 13 ARCHITECT El ENGINEER 0 DEVELOPER 0 TENANT
CONTCORAMREf 32-12�5 NSE NUMBER 74 LICENSE TYPE BUS.LIC#
= M()-qs e- n I
COMPANY NA.ME. �:)CUOiy) E-MAIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE
2-64 lruclee Lauc ,:LC
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK ti
P�X tsfi ba -(a6f pr('Yl±
EXISTING USE PROPOSED USE CONSTR.TYPE I #STORIES
noiw Je. T(6,4 USE TYPE OCC SQFT. VALUATION
EXISTG NEW FLOOR DEMO TOTAL
AREA- AREA A NET AREA ()C 0
BATHRO6MKITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA,�W
PORCH AREA I DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH
[]ATTACH
#DWELLING UNITS: IS A SECOND UNIT 0 YES SECOND STORY OYES
BEING ADDED? [31qO ADDITION? 2m
PRE-APPLICATION 0 YES IF YES,PROVIDE COPY OF ISTHE BLDG AN 0 YES AL VALUATION:
PLANNING ADPL# 0 NO PLANNING APPROVAL LETTER EICHLFRHOME? ffKO J_I 1Z I 1i q0
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act��roperty 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
ordinances and state laws relating to b it i 'g construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Ag Date: 20.
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for nOVER-THE-COUNTER, 11 BUILDING PLAN REVIEW
ex_—isting building(s). Demolition permit is required prior to issuance of building
permit for new building. I EXPRESS 13 PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ItVSTANDARD PVBLICWOWCS
To— 13 nn if any Hazardous Materials are being used as part of this project. 11 LARGE 171 FIRE DEPT
—Copy of Planning Approval Letter or Meeting with Planning prior to 171 MAJOR 0 SANITARY SEWER DISTRICT
submittal of Building Permit application. Q ENVIRONMENTAL HEALTH
B1dgApp__201 1.doc revised 06!21111
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21436 RUMFORD DR DATE: 12/20/2013 REVIEWED BY: MELISSA
APN: 326 � Oa8 B>P#: ?. -VALUATION: $212,840
*PERMIT TYPE: Building Permit PLAN CHECK.TYPE: Alteration 1 Repair
PRIMARY PENTAMATION 1 R3SFDREM
USE: SFD or Duplex PERMIT TYPE:
WORK RECONFIGURE& REMODEL MASTERBED MSTRBTH & UTILITY ROOM 713 S.F. . UPDATE
SCOPE ELECTRICAL& REPLACE (3)WINDOWS & DOORS IN REMODEL AREA(SHIFT UTILITY RMLi
p
)Wech, Plan 'hec:k Phanh Pllarr(,'heck IElec.flan
v1e<;h, Pertnit h`0(>: plumvb,PermitFee: � � I lec, Ilerrnit Fee.
0he Ll�eh, Insp, Other Plumb 1n,V), Oilier Elec_Insp,
l'h,r=rt, I?sp, Fee, I iec.Inst.F"e:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the relimina information available and are onjL an estimate Contact the De t or addn'l in o.
FEE ITEMS LFee Resolution 11-05-3—E 7111131 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00713 s.f. Remodel,Other
Suppl.PC Fee: Reg. 0 OT 0,0 hrs $0.00 $558.00 1REMRESOTH
PME Plan Check: $0.00 3 # Window/Sliding Glass Boor
Permit Fee: $0.00 $418.00 1WINREP Replacement
Suppl. Insp.Fee-0 Reg. 0 OT Q,Q hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee:' $0.00
1rlttz;ritr�ativ�I"ce:
Work Without Permit? 0 Yes 0 No $0.00 E)
Advanced Planning Fee: $0.00 Select aNon-Residential
Building or Structure 0
rcvel t7ocionenialfon Fees: d
Strong?Motion Fee. 1BSEISMICR $21.28 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $9.00
QTI $30.28 $976.00 T # AL � $1,006.28
Revised: 10/01/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: Z1 14ij^r_0 a 12 Pa_ f'01'4 PERMIT# )3 17- 01-4-6
OWNER'S NAME: 5-,Ar,14 I O" L, &:,,Otsy PHONE# k05) 304-TZ31
GENERAL CONTRACTOR: iALjj OCS16,v � &iLQ BUSINESS LICENSE#
ADDRESS: ZS-Lj finuCkEt- t,,,V, SJ , V136 CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
-Sheet Rock
Tile
) ,- 30 ,_ L� -
Owner/Contractor Signature Date