12090117CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10657 RANDY LN
CONTRACTORi4BB---%- B£ PERMIT NO: 12090117
�£TTEI2MINE1)
OWNER'S NAME: NGUYEN THANH H & HAO T
�' DATE ISSUED: 03/05/2013
OWNER'S PHONE: 4084148810C
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL L1 COMMERCIAL0
LICENSED CONTRACTOR'S DECLARATION
License Class Lic.# n
��k /
ADDITION OF 594 SQ FT TO REAR OF 1 STORY SFDWL
Bffit ./ V 1.
0 3 —13
BEDROOM, BATHROOM, AND LIVING ROOM
TO HOME
Contractor aY1d�gate
W/WETBAR,CONVERT EXISTING BEDROOM
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
Sq. Ft Floor Area:
Valuation: $71000
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: 31602046.00
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 OF PERMIT 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 DAY OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Z /
Issued by: Date'
granting of this permit. Additionally, the applicant understands and will comply
with all non -point ource re u ations pert the Cupertino Municipal Code, Section
9.18.
'3 u��twr . �� `� ' �" � 0 S -�
g , ,„ r „ u s, rIJate
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Y' r�
installed without first obtaining an inspection, I 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,
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
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
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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
air contaminants as defined by th Bay Area Air Quality Management District I
will maintain compliance with th Cupert' -Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sectio s 25505, 5533, and 25534.
Section 3700 of the Labor Code, for the of the work for which this
s r �• a
performance
p
_
Own tutlror-ozed agent ' ' Dater
permit is issued.
L�
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
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. 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
3
CONSTRUCTION PERMIT APPLICATION
,+ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVI O �\
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 lj I��
(408) 777-3228 •FAX (408) 777-3333 • building(a)cupertino.org \ V
❑ NEW CONSTRUCTION ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS_-, 65 j'� ^ ` L ,� , a �
-
�\/
APN #
OWNER NAME �f'� • � / � (� ,� /
STREET ADDR SS
CITy,2S AT ZI ��
FAX
CONTACT NAME �1 , i
PHONE 40 (�- 2 ^`9691
U/�^`�
E-MAIL i �rK�Es� _
STREET ADDRESS 1 &59 5!� j � E51 , ^
�(� �� .� �
CfI'Y, STATE, ZIP
FAX
NI OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRAC OOJRGAIGENT 9"'ARCHCIECT W ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME X •
I
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
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EXI ING USE
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,IJ
PROPOSED US CONSTR
���III �� nllV
TYPE
ORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG i`fl
F
AREA to
t(/
NEW FLOOR`
AREA �
DEMO
AREA O
TOTAL �y
NET AREA % ay
J d
a
r
p
T
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
- r
b
C
-
PORCH AREA
DECK AREA
TOTAL DEC RCH AREA
GARAGE AREA: EYDETACH
I
j�� ,•�� ❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT YES
SECOND STORY ❑ V •S
BEING ADDED? ❑NO
ADDITION? l
PRE APPLICATION El YES IF YES, PROVIDE COPY OF
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
IS THE BLDG AN.
EICHLER HOME." NO
RECEIVED BY:`
G
T TAL LUATION:
.
�
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 iscorrect. have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
rrtei
ordinances and state laws relating to buildin onst'r authorize representatives of Cupertino to enter the property for inspection purposes.
-pabove-identified
Signature of Applicant/Agent: Ci/ Date: 1
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
RoiiTiNc stir'
El
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
OVER THE -COUNTER`
Btnt DINa PLnN REVIE�y
permit IOC new building.
❑ EXPRESS ..
PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
TANDARD
PUBLICwORKS
form if any Hazardous Materials are being used as part of this project.
LARGE `
L)Q FIItE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MA IOR
submittal_ of Building Permit application.
%ARY SEWER DISTRICT
SANIT
"'"
❑'; ENVIRONMENTAL"HEALTII
BldgApp_2011.doc revised 06/21/11
ma
I,5[oal
Aff
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
v
ADDRESS: 10657 Randy Lane
DATE: 09/13/2012
REVIEWED BY: Sean
PC FEE ID
APN:
BP#:
*VALUATION: 1$71,000
II-B,111-B,IV,V-B
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY
USE: SFD or Duplex
2nd Unit? Yes ' No
OTC? 0Yes No
PENTAMATION
PERMIT TYPE: 1R3SFDADD
a
WORK
Construct a 594 sq ft one story addition.
SCOPE
0,0
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
594
$2,468.00
IR3PLNCK
$1,549.00
IR3INSP
Elec. Insp. Fee:
$1,549.00
Suppl. Insp. Fee:Q Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Constrztction Tax:
Administrative Fee:
0
0
Work Without Permit? 0 Yes (j) No
$0.00
TOTALS:
594
$2,468.00
Travel Documentation Fees:
$1,549.00
Strong, Motion Fee: 1BSEISMICR
MECH, HOURLY 0 Yes 0 No
PLUMB, HOURLY Q Yes Q No
ELEC, HOURLY Q Yes Q No
.Ltech. Plan Check
Plumb, Plan Check
Elec..Plan Check
:Lfech. Permit Fee..
Plrnnb. Permit Fee:
Elec. Permit Fee:
Other alech. Insp.E17--
Other Plumb Insp.E17--
Other Elec. Insp.
.Rech. Insp. Fee:
Plumb. hrsp. 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 feet are hated on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,468.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: 0 Reg. ® OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,549.00
Suppl. Insp. Fee:Q Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Constrztction Tax:
Administrative Fee:
0
0
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee: 1PLLONGR
$77.22
Select a Non -Residential 0
Building or Structure
i
Travel Documentation Fees:
Strong, Motion Fee: 1BSEISMICR
$7.10
Select an Administrative Item
1
Bldg Stds Commission Fee: IBCBSC
$3.001
SUBTOTALS:
$4,104.32
$0.00 TOTAL FEE:
$4,104:32
Revised: 07/01/2012
CUPERTINO
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST- • C
JOB ADDRESS: / W7 AN lj
PERMIT # %
OWNER'S NAME: %h 411-1d, U ,
PHONE # D'g
GENERAL CONTRACTOR: ''
BUSINESS LICENSE #
ADDRESS: J G/
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 OCCUP NCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL S CONTRACT RS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
17 S nature Date
Please check applicable subcontractors and complete the following information:
d
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
Owner / Contractor Signature
Date