15010185 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10646 LA RODA DR CONTRACTOR:AAA CONSTRUCTION PERMIT NO: 15010185
SERVICES
OWNER'S NAME: ADKINS RICHARD B AND LINDA PO BOX 110971 DATE ISSUED:01/30/2015
OWNER'S PHONE: 4082577359 CAMPBELL,CA 95011 PHONE NO:(408)510-9382
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
KITCHEN REMODEL; TO INCLUDE CONVERTING(E)
License Clas # 6Z GARAGE
SPACE INTO COND.KITCHEN SPACE 422 SQ FT
Contracto ate S
I hereby affirm that i am licensed under the provisi s of hapter 9 REVISION#I-OMIT SHEARWALLS-1SSD OTC
(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 th `` 01
performance of the work for which this permit is issued. S or Area: Valuation:$20000
I have and will maintain Worker's Compensation Insurance,as ptovidc r by
Section 3700 of the Labor Code,for the performance of the work 1`0 is is
APN Number:36933015.00 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 T 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point a 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,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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)
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
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,Sectio r 5 3,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,l 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.1 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 1 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10646 la roda dr DATE: 02/05/2015 REVIEWED BY: Mendez
APN: BP#: �- Q *VALUATION: Iso
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION
USE: PERMIT TYPE:
WORK REVISION#1- OMIT SHEARWALLS- ISSD OTC
SCOPE
El
r 4.
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/131 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: 0 Reg. Q OT TO.01 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-0 Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Work Without Permit? 0 Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Building or Structure
A
Strong Motion Fee: $0.00 FO.5 hrs Admin./Clerical Fee
Bldy,Stds Commission Fee: $0.00 $45.00 IADMIN
SUBTOTALS; $0.00 $45.001 TOTAL FEE. $45.00
Revised: 01/06/2015
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10646 LA RODA DR CONTRACTOR:AAA CONSTRUCTION PERMIT NO: 15010185
SERVICES
OWNER'S NAME: ADKINS RICHARD B AND LINDA PO BOX 110971 DATE ISSUED:01/30/2015
OWNER'S PHONE: 4082577359 CAMPBELL,CA 95011 PHONE NO:(408)510-9382
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL ❑
nn KITCHEN REMODEL; TO INCLUDE CONVERTING (E)
License Class V Lic.# GARAGE
� � SPACE INTO COND.KITCHEN SPACE 422 SQ FT
Contractor /
C ��/ Dated (° ,� �
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
1i
pe formance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$20000
1 ave and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:36933015.00 Occupancy T
permit is issued. p y ype'
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, l 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 DAYS F 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
Date-
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
J RE-ROOFS:
Signature Date t3� /S All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection,l agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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)
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. 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 Bay Area Air Quality Management District 1
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 theerformance of the work for which this
permit is issued. p Owner or authorized agent: /J°�% Date: 9J�
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 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
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10646 la roda dr DATE: 01/30/2015 REVIEWED BY: Mendez
APN: BP#: �j(,�� *VALUATION: 1$20,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM
USE: PERMIT TYPE:
WORK kitchen remodel- to include convertin a garage space into cond.kitchen space 422 sq ft
SCOPE
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ejf%//%13FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F-422--1 s.f. Remodel,Other
Suppl. PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 $503.00 IREMRESOTx
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Work Without Permit? 0 Yes (F) No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential G
Building or Structure 0
A
Strong Motion Fee: IBSEISMICR $2.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.001 1
SUBTOTALS: $3.60 $503.00 TOTAL FEE; 1 $506.60
Revised: 01/06/2015