12050125CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1079 KENTWOOD AVE CONTRACTOR: R & R BUILDING AND PERMIT NO: 12050125
1 MAINTENANCE I
I OWNER'S NAME:
License Class P-=:1 Lic. # IRL+ IQ, cl�
ContractorlZ Date
I hereby affirm that I am licensed unher 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 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 no7 ce regulations per the Cupertino Municipal Code, Section
9.18.
Signatu Date
El OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law forone 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
,ranting of this permit. Additionally, the applicant understands and will comply
"ith all non -point source regulations per the Cupertino Municipal Code, Section
18.
�iature Date
BUILDING PERMIT INFO: BLDG r— ELECT F PLUMB
MECH r— RESIDENTIAL COMMERCIAL F
JOB DESCRIPTION: ADD 499 SQ FF TO LIVING AND OFFICE
SPACE -STRUCTURAL
Sq. Ft Floor Area: I Valuation: $125000
APN Number: 35930013.00 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: Date6au:95
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. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) 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, Sections 25505,25533, and 25534.
Owner or authorized agent:
Date: -4A
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 Add
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professiona
CITY OF CUPERTINO
Mr -0 FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE-
ADDRESS: 1079 kentwood dr.
DATE: 05/15/2012
REVIEWED BY: bobs.
PC FEE ID
APN:
BP#: 050 jo-Z 5-
*VALUATION: 1$125,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
2ndUnit? — OYes ON
OTC? 0 Yes (2) No
PENTAMATION 1R3SFDADD
PERMIT TYPE:
WORK
structral.
I
SCOPE
��nq/office
OCCUPANCY TYPE-
TYPE OF
CONSTR.
FLR AREA
(S.f.)
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
11-B,111-B,1V,V-B
499
$1,482.00
IADDPLCK
$1,205.00
IADDINSP
CV1-,!C,A
$1,205.00
Suppl. Insp. Fee -.0 Reg. 0 OT
Elec. 11an Ow."k
hrs
F� Pen; i h
PME Unit Fee:
Peini( Fee.
F /cc. Permii Fue.
$0.00
01her Ucg,,A_ lq,�p
Cmf.,.� rruction - Tax:
I
0�11;trr Plfl.rnl', Imp
Li
,-j.1,N1i17iSWorw(? POO.
01;, , 1, Ins/i. Li
0
G
Al'.(h. fil�p. Fce.
$0.00
TOTALS:
499
$1,482.00
Trovel Doczimentalion Fees.
$1,205,00
Strony, Motion Fee: IBSEISMCR
NOTE: This estimate does not includefees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the Preliminary information available and are on1v an estimate- Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711111)
M,
11X
10
MISC ITEMS
Plan Check Fee:
$1,482.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (E) Reg. 0 OT
1 0.0
, M.'a Mil
_24— —
$0.00
1,r.,(Jq. Plan 'hed,
$0.00
CV1-,!C,A
$1,205.00
Suppl. Insp. Fee -.0 Reg. 0 OT
Elec. 11an Ow."k
hrs
F� Pen; i h
PME Unit Fee:
Peini( Fee.
F /cc. Permii Fue.
$0.00
01her Ucg,,A_ lq,�p
Cmf.,.� rruction - Tax:
I
0�11;trr Plfl.rnl', Imp
Li
,-j.1,N1i17iSWorw(? POO.
01;, , 1, Ins/i. Li
0
G
Al'.(h. fil�p. Fce.
$0.00
I
Plunih. fas/). Fue,
Select a Non -Residential E)
Building or Structure 0
Trovel Doczimentalion Fees.
Flc( Insp. Fce.
Strony, Motion Fee: IBSEISMCR
NOTE: This estimate does not includefees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the Preliminary information available and are on1v an estimate- Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711111)
FEE
QTYIFEE
MISC ITEMS
Plan Check Fee:
$1,482.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (E) Reg. 0 OT
1 0.0
1 hrs
$0.00
PME Plan Check:
$0.00
Perinit Fee:
$1,205.00
Suppl. Insp. Fee -.0 Reg. 0 OT
I-0-.0-1
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Cmf.,.� rruction - Tax:
,-j.1,N1i17iSWorw(? POO.
0
G
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Pl4nninp _Fee: PLLONGRNGR
$64.87
Select a Non -Residential E)
Building or Structure 0
Trovel Doczimentalion Fees.
Strony, Motion Fee: IBSEISMCR
$12.50
Select an Administrative Item
Bldp, Stds Commission Fee: IBCBSC
$5.00
"f'o '?gw-��; v, I
$2,769.37
,q
Z0
.769.37,
Revised: 04/01/2012