11110014CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10786 BROOKWELL DR
CONTRACTOR: PETER
PERMIT NO: 1. 1 1 10014
CONSTRUCTION
OWNER'S NAME:
SAN JOSE, CA 95129
PHONE NO: (408) 529-6412
❑ LICENSED CONTRACTOR'S DECLARATION
r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. H
r r r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: SFDWL ADDITION OF ENTRY,LIVING
ROOM,BEDROOM,BATH(646SQFT)&ADD I WINDOW &
(commencing with Section 7000) of Division 3 of the Business & Professions
RE-ROOF(20SQFT)&RE-LOCATE DRIVEWAY
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
Sq. Ft Floor Area:
Valuation: $90000
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.
APN Number: 36921035.00
Occupancy Type:
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
Issued Date:
granting of this permit. Additionally, the applicant understands and will comply
b.
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, 1 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. 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, Sect' ns 25505. 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date: V L_1n3._�N
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 Califomia. If, after making this certificate of exemption, 1
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
1 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 Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FM_7FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10786 brookwell dr.
DATE: 11/03/2011
REVIEWED BY: bobs.
APN:
BP#:
'"VALUATION: 1$90,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Du lex
USE: P
2nd Unit? Yes • No
OTC? 0 Yes DNo
PENTAMATION 1R3SFDADD
PERMIT TYPE:
WORK
sfd add entry, living room bedroom bath add 1 window, re -roof.
SCOPE
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-B,IV,V-B
646
$2,420.00
IR3PLNCK
$1,519.00
IRRNSP
TOTALS:
646
$2,420.00
$1,519.00
MECH, HOURLY 0 Yes 0 No
PLUMB, HOURLY 0 Yes 0 No
ELEC, HOURLY 0 Yes 0 No
ET_1__
El
NOTE: This estimate does not include fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc ). These fees are based on the Drelin=nary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (! ee Resolution 11-053 L; . 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,420.00
1 I# Window / Sliding Glass Door
$783.00 iwwN EwsTR New (Shearwall/Masonry)
Suppl. PC Fee: 0 Reg. 0 OT
0.0 1
hrs
$0.00
PME Plan Check:
$0.00
2,000 s.f. Re -roof
$280.00 IREROOFRES
Permit Fee:
$1,519.00
Suppl. Insp. Fee-.0 Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
,'GC/J7tiFilh`t!"tlttlie.' le'E,'"
0
0
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee: PLLONGRNGR
$83.98
Select a Non -Residential 0
Building or Structure 0
i
°c;v�! LYo<rrrrrcrnTcFru�rr_ Ic�w
Strong Motion Fee: IBSEISMICR
$9.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$4.00
SUBTOTALS:
$4,035.98
$1,063.00 TOTAL FEE:
1 $5,098.98
Revised: 10/01 /2011