13050092 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21962 WOODBURY DR CONTRACTOR:JEFFREY MILLER, PERMIT NO: 13050092
GENERAL CONTR
OWNER'S NAME: ARNOLD CROSS 1550 DELL AVE SUITE I DATE ISSUED:05/13/2013
OWNER'S PHONE: 4082576052 CAMPBELL,CA 95008 PHONE NO:(408)866-1345
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIALE]
License Class Li .# �� REMODEL BOTH(E)MASTER&HALL BATHS,
� RECONFIGURE
Contractor Date MASTER SHOWER COMPARTMENT&REPLACE(E)
I hereby affirmtha am licensed under the provisions of Chapter 9 WINDOW
(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 corder 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:$26000
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:32639020.00 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 DAYS FROM 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 Date:
granting of this ermit. Additional) the applicant understands and will complyIssued b
g g P Y, PP� �' `
with all non-poin sourceulation er the Cupertino Municipal Code,Section
9.18. . -- _
GOOFS:
Signatur 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
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)
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 tine 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 C pertino Mmrici al Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5 33 a 5534.
Section 3700 of the Labor Code,for the performance of the work for which this 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 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(Sec.3097,Civ C.)
Lenders 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
i
i
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21962 WOODBURY DR DATE: 05/13/2013 REVIEWED BY: MELISSA
APN: 326 39 020 *VALUATION: $26,000
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION 1 R3SFDREM
USE: SFD or Duplex PERMIT TYPE:
WORK REMODEL BOTH E MASTER & HALL BATHS RECONFIGURE MASTER SHOWER
SCOPE COMPARTMENT& REPLACE (E)WINDOW
Xlech, Plora Check Plumb. Plao Check Dec.1%carr C'hec%
ri-feeh.Permil Fee: P/rrrrrh. Permit Fce: E/ac. Pernri7 I c>cs:
Other rllech, Iasi). Other P/arrrah hasp, Other Elec.InsP.
,Wcch. M.sp,Fco. Phmtb, hr.rp, Fee: Elec.Imp.Fee:
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 prelintinar information available and are only an estimate. Contact the Dept-for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff.' 711/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F 130 s.£ Remodel,Bath(<=300 sf)
Suppl.PC Fee: Q Reg. Q OT0.0 hrs $0.00 $600.00 IREMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:Q Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Constrrtctien Tn:c:
ALhninistrative_Fee:
Work Without Permit? 0 Yes (F) No $0.00
Advanced Planning Fee. $0.00 Select a Non-Residential 0
Building or Structure 0
Trmwa Docurrietltutiurr Tees:
Strong Motion Fee: 1BSEISMICR $2.60 Select an Administrative Item
i
Bldy Stds Commission Fee: IBCBSC $2.00
SUBTOTALS: $4.601 $600.001 TOTAL FEE: 1 $604.60
Revised: 04/29/2013 j
I
CONSTRUCTION PERMIT APPLICATION }
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE.AVENUE•CUPERTINO,CA 95014-3255 I
(408).777-3228• FAX(408)777-3333•building a(,.cupertino.org
❑NEW CONSTRUCTION . El ADDITION: ❑ ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT# '
�y APN
#
PROJECT ADDRESSCt � -39 0
OWNER NAME PHONE. ' - J� a`? E-MAIL
FAX
STREET ADDRESS * .w , f ,;. CITY, TTE ✓ -/ aC FI (� � �pf
CONTACT NAME ..y L .. E MAII
fi
STREET ADDRESS a 1 CITY,STATE,ZIP FAx
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSENUMBERr�° LICENSE TYPE i BUS.LIC#
� ( / 2
COMPANY NAME j� fes, ' E-MAI �' ak r 0 fi n'*
f Z E f t
It ., r f ` 1 l t 1 �; �'.) l/ l f d J.Y '�, "� , t
STREET ADDRESS /, y t9 d� j CITY,STATE,ZIP l � PHONE1 .,.JX� .
ARCHITECTIENGINEERNAME LICENSENUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK Z'y ./ r Cn
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION
EXISTGNEW FLOOR DEMO TOTAL
AREA - ' -.ARBA AREA NET AREA
BATHROOM KITCHEN OTHER .
REMODEL AREA /'. *<. REMODEL AREA REMODEL AREA
.PORCH AREA .DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH .
#DWELLING UNITS:" ISA'SECONDUNIT EYES SECOND STORY EYES '
BEING ADDED? ❑NO ADDITION? [:]NO
'
.PRE-APPLICATION [-]YES IF YES,PROVIDE COPY OF. IS THE BLDG AN El YES RECEIVED Bl�. _, >_. TOTAL VALJJATION;
'PLANNING APPL#, ❑NO PLANNING APPROVAL LETTER EICHLERHOME? ❑NO
G
By my signature below,I certify to e#otheollowing: I r�n the property owner or authorized agent to act on the property.owner's behalf. I have read this
application and the information I hai$`eorrect. 0have read the Description of Work and verify It is accurate. I agree to comply with all applicable local
ordinances and state laws relating toTio. ,authorize representatives of Cupertino to enter the above-Inhfie prQ rty for inspection purposes.
Signature of Applicant/Agent: Date: c
SUPPLEMEN ALttt RMATION REQUIRED PL 11y CHECICTYPE = L.sovTrriGsnrI ,
New SFD or-Multifamily dwellings: Apply for demolition permit for OVERT> couNTCR - Z suHD vcPLAN]REINi w
existing building(s):.Demolition permit is required prior to issuance of building
3
permit for new building.
ExPREss x ❑ .eLAxNlriGSLANx>vlEw
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STAbIDARD - ❑ IJBilewoRxs
64
form if any Hazardous Materials are being used as part of this project. LARGE =>�tEDT Pr s i
_Copy of Planning Approval Letter or Meeting with Planning prior to I�IA3oli xn
❑'SANITARY SEWER�ISTRICT.
submittal of Building Permit application.
❑�ENYIltONMENT'A7;�A1.TH.-' .�. N
BldgApp 201 Ldoc revised 06/21/11
I
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT i N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: r t / � PERMIT# 3 � U
OWNER'S NAME: > .� PHONE# -' m
GENERAL CONTRACTOR:. .� 4 ,(U C X BUSINESS LICENSE#
ADDRESS: ePC, CITY/ZIPCODE: v t n
*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
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Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
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