11060032 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10240 RANDY LN CONTRACTOR:BURSTEIN LOUBA PERMIT NO: 11060032
OWNER'S NAME: BURSTEIN LOUBA 10240 RANDY LN DATE ISSUED:06/03/2011
FR'S PHONE: 4083430232 CUPERTINO,CA 95014 PHONE NO:
EJ LICENSED CONFRACI'OR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
LicenSt Class I_.tc-#
MECH F RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: KITCHEN REMODEL(240SQFT)NON-STRUCTURAL TO
(commencing with Section 7000)of Division 3 of the Business&Professions INCLUDE
ELECTR C,MECHANICAL&PLUMBING
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.
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 Sq.Ft Floor Area: Valuation:$3000
permit is issued.
APPLICANT CERTIFICATION APN Number:31623094.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
grantors of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9J8
Issued b Date: (� `
Signature Date '
OWNER-BUILDER DECLARATION
JX RE-ROOFS:
1 hereby,affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,l agree to remove all new materials for
1.as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three '
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
perfornnance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined b 'the Ba Area Air
y' y Quality Management District I will
I certify that in the performance of the work for which this permit is issued,1 shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must Owner or ut o ized ag nt.,
forthwith comply with such provisions or this permit shall be deemed revoked. �� Date:
c
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a'construction lending agency for the performance of vork's
correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
co-s,and expenses which may accrue against said City in consequence of the
ng of this permit.Additionally,the applicant understands and will comply
all non-point sour
ce,re lations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
1 K I I understand my plans shall be used as public records.
?/,//Signature_Signature Date ? Licensed Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10240 RANDY LN CONTRACTOR: BURSTEIN LOUBA PERMIT NO: 11060032
OWNER'S NAME:
CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION F
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. II
Contractor
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.
1 hereby affirm under penalty of perjury one of the following two declarations:
l 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.
1 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
permit is issued.
APPLICANT CERTIFICATION
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
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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
Id OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for on"e of
the following two reasons:
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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations: /
1 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.
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
permit is issued.
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
correct. l 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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point sour c�re lations per the Cupertino Municipal Code, Section
9.18.
/ Date J /� I Licensed Professional
RM�� CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10240 randy lane
DATE: 06/03/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION: 1$3,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
sfd kitchen remodel non structural include M E Ps.
SCOPE
t' . r
El E3__L__ Li
NOTE. These tees are based on the nrelindnary information available and are onlv an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 E '. 711110)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= s.f.
$570.00
Remodel, Kitchen (<=300 so
IREMRESKIT
Suppl. PC Fee: 0 Reg. 0 OT
1 0.0
1 hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee-0 Reg.
0 OT
FO.0
h.rs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
{ ou":Irtic'fiwl 74V
Acoustical Fee:
0 Yes 0 No
$0.00
0
0
Work Without Permit? 0 Yes (E) No
$0.00
Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Q
0
i
f rar.-e I
Strong- Motion Fee:
1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$1.50
$570.00
TOTAL FEE:
$571.50
Revised: 04/29/2011