12080215CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 1138 KENTWOOD AVE
OWNER'S NAME:
13 LICENSED CONTRACTOR'S DECLARATION
License Class- Lic. 4 -
tractor t4l L�ro ;�
Con (P Dat
4-
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.
CONTRACTOR: CENTURY DEVELOPMENT PERMIT NO: 12080215
CONSTRUCTION
5487 CRIBARI GRN DATE ISSUED: 08/28/2012
SAN JOSE, CA 95135
PHONE NO: (510) 557-4176
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r—
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: SFDWL ADDITION OF 250 SQ FT TO REAR OF FAMILY
ROOM
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 Sq. Ft Floor Area:
Section 3700 of the Labor Code, for the performance of the work for which this I
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
witb-DIjiRn-pzin11spyrce.reg tions tb1C:Quper4mCi MUtijripaJ Code, Srction
t
Signatur . . . . .......... Nita SQ. r--, - Aw -P.—
OWNER-B LDER DECLARATION
t
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 afTirm 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.
Signature Date
APN Number: 35931054.00
Valuation: $30000
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 beirig installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
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. Iwillmaintain
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.
CONSTRUCTION LENDING AGENCY
I hereby affirm that re is a construction lending agency for the performance of Wrk's
for which this permit i rissued (Sec. 3097, Civ C.)
Lender's Name
Lender's Ad
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professiona
CITY OF CUPERTINO
FM_7 FEE ESTIMATOR — BUILDING DIVISION
OCCUPANCY TYPE:
DDRESS: 1138 Kentwood Ave
DATE: 08/20/2012
REVIEWED BY: jsg
PC FEE ID
A p N
BP4:
*VALUATION: F$30,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
2nd Unit? 0 Yes E) No
� OTC? 0 Yes E)No
PENTAMATION 1R3SFDADD
PERMIT TYPE: 19
woRK
ft addition in rear, single story
SCOPE
��q
OCCUPANCY TYPE:
TYPE OF
CONSTR
FLR AREA
J.)
PC FEES
PC FEE ID
' BP FEES
BP FEE ID
R-3 (Custom)
11-B,111-B,1V,V-B
250
$1,014.00
JADDPLCK
$983.00
JADDINSP
Permit Fee:
$983.00
Suppl. Insp. Fee -.0 Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
("'on vrl lotion Y'erv..
P-ec..
0
E)
Work Without Permit? 0 Yes No
$0.00
TOTALS:
250
$1,014.00
o*,) n. 1.1;�'.�.
$983.00
Strong Motion Fee: IBSEISAffCR
""V0�
. ...........
's
.......... .............. W,
MISC ITEMS
Plan Check Fee:
Plan Cr .11,
b
Pei Fcc.
M:orl;"
El
ET
PME Plan Check:
$0.00
Permit Fee:
NOTE: This estimate does not includefees due to other Departments (Le. Planning, Public Works, Fire, Sanitaq Sewer District, School
District,etc.). These fees are based on thepreliminary information available and are onlv an estimate. Contact the DeDt for addnl info.
FEE ITEMS (Fee Resolution 11-053 Eff 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$1,014.00
Select a Misc Bldg/Structure
or Element of a Building 'A
Suppl. PC Fe e: (F) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$983.00
Suppl. Insp. Fee -.0 Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
("'on vrl lotion Y'erv..
P-ec..
0
E)
Work Without Permit? 0 Yes No
$0.00
Advanced Planniqg Fee. IPLLONGR
$32.50
Select a Non -Residential 0
Building or Structure 0
o*,) n. 1.1;�'.�.
Strong Motion Fee: IBSEISAffCR
$3.00
Select an Administrative Item
Bldjz Stds Commission Fee: IBCBSC
$2.001
... ...... .... ......
5'
$2,034. 0
1 0. 0 0 R T
2,034.501
s.
Revised: 07/0112012