10110192I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 858 SEPTEMBER DR
OWNER'S NAME:
1 FREMONT, CA 94555 1 PHONE NO: (510) 908-5244
�I
LICENSED ONTRACTOR'S DECLARATION
License Class JK Lic. 4S7,4=0
Contractor �- Date
la -
I hereby affirm that 1 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.
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
Section 3700 of the Labor Code, for the performance of the work for which
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 constriction, 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 r latio er the Cupertino Municipal Code, Section
9.18.
Signature Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one 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:
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
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
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
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.
Sign
Date
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: ADD 606 SQ FT TO LIVING, BEDRM AND
BATHROOM,15.75
TO PORCH REMODEL 168 KITCHEN, 45 BATH & 355
THROUGH OUT STRUCTURAL
Sq. Ft Floor Area: I Valuation: $150000
APN Number: 36214017.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code,Aections 25505, 25533, and 25534.
Owner
Date: i
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
CITY OF CUPERTINO
MM -N, FEE ESTIMATOR — BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS: 858 September Dr.
DATE: 11/30/2010
REVIEWED BY: gs
PC FEE ID
APN:
BP#:
'VALUATION: 1$150,000
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
OVER THE
COUNTER. Q Yes Q No
PENTAMATION 1 R3SFDADD
PERMIT TYPE:
WORK
l let. Insp. Pee:
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,111-B,IV,V-B
622
$2,349.00
IR3PLNCK
$1,474.00
IR3INSP
l let. Insp. Pee:
PME Plan Check:
$0.00
= s.f.
$570.00
Remodel, Kitchen (<=300 sf)
1REMRESKIT
Permit Fee:
$1,474.00
Suppl. Insp. Fee49 Reg. Q OT
0.0
hrs
$0.00
551 s.f. Remodel, Other
$443.00 IREMRESOTH
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
#
$0.00
TOTALS:
622
$2,349.00
$1,474.00
M.ECH, HOURLY Q Yes 0 No
PLUMB, HOURLY Q Yes Q No
ELEC, HOURLY Q Yes Q No
1,1m7i. Plan Clgeck
Phu/b. Plun Check
Llec. Plan Check
Mecfc. Permit Fee.
Phrmh. Permil Fee.
Elec. Permit Fee.
Oilier ;l/ech. Insp.
Other Plumb /nsp,
Outer Elec. Insp. Li
Alech. In.,p. 1°'c<c:
Plwah. Insp. F-e:
l let. Insp. Pee:
NOTE. These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn 7 info.
FEE ITEMS (Fee Resolution 09-051 a. 711/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,349.00
45 s.f.
$570.00
Remodel, Bath (<=300 sf)
IREMRESBAT
Suppl. PC Fee: 0 Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
= s.f.
$570.00
Remodel, Kitchen (<=300 sf)
1REMRESKIT
Permit Fee:
$1,474.00
Suppl. Insp. Fee49 Reg. Q OT
0.0
hrs
$0.00
551 s.f. Remodel, Other
$443.00 IREMRESOTH
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
#
$0.00
Covered Porch
Conswuction Tax
Acoustical Fee: 0 Yes (E) No
$0.00
E)
Work Without Permit? Q Yes 0 No
$0.00
Planning Fee: PLLONGRNGR
$80.86
Select a Non -Residential
Building or Structure
E)
Travel Documentation Fees:
Strong Motion Fee: IBSEISMICR
$15.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$6.00
SUBTOTALS:
1 $3,924.861$1,583.00
TOTAL FEE:
1 $5,507.86
Revised: 1110812010