13100044 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10576 LA RODA DR CONTRACTOR:NORTH CURRENT PERMIT NO:13100044
BUILDERS
OWNER'S NAME: TOM&JOANNE CARR 6433 DU SAULT DR DATE ISSUED:10/04/2013
OWNER'S PHONE: 4082570402 SAN JOSE,CA 95119 PHONE NO:(408)892-0071
ED �LICsENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALU
License Class Lic. KITCHEN REMODEL TO INCLUDE M,E,P'S 108 SQ FT TO
INCLUD REMOVAL AND REPLACEMENT OF DOOR,
Contractor SERVICE
I hereby affirm that I am licensed under the provisions of Chapter 9 PANEL UPGRADE 200 AMP,AND UPGRADE 12 LIGHTS
(commencing with Section 7000)of Division 3 of the Business&Professions THRU
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. Sq.Ft Floor Area: Valuation:$35000
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:36933020.00 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 WI 0 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 DrJOM LAST CALLED INSPE TI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 22
costs,and expenses which may accrue against said City in consequence of the Issued by Date: / J
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. 41
RE-ROOFS:
Signa s- Date 5 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
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. 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 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 ,25533 5534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent Date (a l
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 be 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
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
F1 ADDRESS: 10576 la roda dr DATE: 10/04/2013 REVIEWED BY:
APN:
BP#: *VALUATION: $35,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY �PPENTA�M�ATION 1 R3SFDREM
USE: SFD or Duplex ERMIi
wORK kitchen remodel to include m e 's 108 sq ft to includ removal and replacement of door, service panel
SCOPE upgrade 200 amp, and upgrade 12 lights thru out, 4 switches
Plan /zc,c.h. Fhw?!).Plan Check LEIec.Plan Check 0.0 hrs $0.00
Llcch_Pc:,Vn it Fee: P1umh. N veil Fee: Elec.Permit Fee: 1EPERMIT
Orher tfec,7�.h7sp. Chher Phimh Insp. Other Elec.Insp. 0.0 hrs $47.00
mech.Jam Fcc: Plurnh. hup.Fee: Etc(.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.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 Dfet for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00108 1 s.£ Remodel,Kitchen(<=300 sf)
Suppl.PC Fee: Q Reg. Q OT 0:0 hrs $O.00F $626.00 1REMRESKIT
PME Plan Check: $0.00 200 amps Electrical
Permit Fee: $0.00 $47.00 IBELEC200 Services
Suppl. Insp.Fee-(F) Reg. ® OT 0.0 hrs $0.00 12 Electrical
PME Unit Fee: $0.00rIF4 #
0 IBREMF= Fixtures,Lighting
PME Permit Fee: $47.00 Electrical
Ct;nslFztction Tax: $
47.00 IBREMRECEP Recep/Switch/Outlets
Administrative Fee: IADMIN $44.00
Work Without Permit? Yes (j) No $0.00
Advanced PlanningFee: $0.00 Select a Non-Residential
Building or Structure
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $3.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $2.00
SUBTOTALS: $143.50 $790.00 TOTAL FEE: $933.50
Revised: 10/01/2013