13020077 CITY OF (CU PIERTIINO BUILDING NG lPlEll MIT
BUILDING ADDRESS: 1133 KENTWOOD AVE CONTRACTOR: PERMIT NO: 13020077
OWNER'S NAME: RAJESH KARNIK DATE ISSUED:04/02/2013
OWNER'S PHONE: 4089823833 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION. RESIDENTIAL❑ COMMERCIAL
11
License Class Lic.# CONSTRUCT A 467 SQ FT ADDITION TO CREATE(N)
LIVING RM,WALK-IN CLOSET&3RD BATH; REMODEL
Contractor Date (E)
I hereby affirm that I am licensed under the provisions of Chapter 9 MSTR]BdDRM(165 SQ]FT); KITCHEN (150 SQ FT);DIN.
(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. Sq.Ft Floor Area: Valuation:$55000
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 I APN Number:35931012.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES 11 WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN ll�®����®� IT ISSUANCE®�
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 FRO AILLED 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 l Z !�
granting of this permit. Additionally,the applicant understands and will comply d e 4
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,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. 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,Section25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this C
Owner or authorized agent: Date:
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 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 a regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature A^" Date 4
CRTY OF CU FIEllBTNG
FEE TEST RMA' OR- BUR LMN G DRVRSRON
ADDRESS: 1133 Kentwood Ave DATE: 0212712013 REVIEWED BY: Sean
APN: ]BP#: �bo��®',� *VALUATION: Iso
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex 2nd Unit? ` Yes No PENTAMATIION 1 R3SFDADD
USE: I OTC. 0 Yes QNo PERMIT TYPE:
WORK CONSTRUCT A 467 SQ FT ADDITION TO CREATE N LIVING RM, WALK-IN CLOSET& 3RD
SCOPE BATH; REMODEL (E) MSTR BDRM (165 SQ FT); KITCHEN (150 SQ FT); DIN. RM (150 SQ FT); EE
OCCUPANCY TYPE: TYPE OF F1LR AREA PC FEES PC]FEE IID BPFEES BP FEE IIID
CONSTR. s.f.
R-3 (Custom) II-B,111-B,IV,V-B 487 $1,512.00 IADDPLCK $1,230.00 1ADDINSP
TOTALS: 487 $1,512.00 $1,230.00121
UY1[]E�ff][,]E ®lUElt][ ' Yes,} No ]P]LIE$,lE][QDU][8]C ' Yes No 1F1[��1)�lG�' s �No
vtC;C.'12,jars d+%t.iiC.'C:A' N,w!'. Plan(.,h
I-ee: 1?'rt!nr..1 er"'Ifi",
(.fil,£:r`�9nL'?],iia.i�,. ()!;:;t'.�'�c 7;t"rL-'j'%r°?. !.)f.•aa�ti'(.,,....1; ,
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the preliminar information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTYIFEEIE MIISC ITEMS
Plan Check Fee: $1,512.00 166 s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: E) Reg. Q OT 0.0 hrs $0.00 $600.00 IREMRESKIT
PME Plan Check: $0.00 315 s.f. Remodel,Other
Permit Fee: $1,230.00 $467.00 IREMRESOTH
Suppl. Insp. Fee:(E) Reg. Q OT 0 0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Work Without Permit? 0 Yes E) No $0.00 0
Advanced Planning Fee: IPLLONGR ita.3`t Select a Non-Residential Q
y^ } pn
UUT Building or Structure 0
Strong Motion Fee: Select an Administrative Item
Bldg Stds Commission Fee: 0.00 ,
�.
SUBTOTALS: 1,0 � �s T®�A]L IFEE
$ 67 00
ix
�$��,a7 r Revised: 0110112013