12030094CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21836 WOODBURY DR
OWNER'S NAME:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.#
Contractor Date
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.
1 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 non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature
CONTRACTOR: CHEN SAMUEL C AND PERMIT NO: 12030094
THERESA K
21836 WODBURY DR DATE ISSUED: 03/20/2012
CUPERTINO, CA 95014-1148 PHONE NO:
BUILDING PERMIT INFO: BLDG r- ELECT i PLUMB r
MECH i RESIDENTIAL F COMMERCIAL r
JOB DESCRIPTION: KITCHEN REMODEL(250SQFT), NEW WATER HEATER,
NEW
FORCED AIR FURNACE, SERVICE PANEL UPGRADE TO
2000AMPS
Sq. Ft Floor Area: I Valuation: $20000
APN Number: 32619070.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date I Issued by:
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
I, 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
l 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 nQn-point source regulations per the Cupertino Municipal Code, Section
9.18. �
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
1 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(a) should I store or handle hazardous material.
Additionally, should 1 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.
:
Date: __1Z ^ �Z
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 Address
ARCHITECT'S DECLARATION
Date
l understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
IJSI FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
21836 woodbury drive
DATE: 03/19/2012
REVIEWED BY: larry s
APN: 3 - _ D
BP#:
"VALUATION: $20,000
'PERMIT TYPE: Building Permit
PLAN CHE30
CK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK I
kitchen remodel les than 300 s . ft. new water heater, new forced air furnace service panel upgrade
SCOPE Ito
200 amps.
Mech. Plan Check
Oro]hrs
$0.00
Plumb. Plan Check
0.
hrs
$0.00
Elec. Plan Check
0.0
hrs $0.00
Mech. Permit Fee: IMPERMIT
Plumb. Permit Fee:
IPPERMIT
Elec. Permit Fee: IEPERMIT
Other Mech. Insp. Rolhrs $44.00
Other Plumb Insp. 0.0 hrs
$44.00
Other Elec. Insp. E hrs $44.00
NOTE: This estimate does not include fees due to other Departments (4e. Planning, Public Works, Fire, Sanitary Sewer District, School
Worirt- Pie-)- Thimp feo_c are howl nn the nralinrnnry infnrmirtlnn nvailahlo and nre nnly an octi►nato_ Cnntnet the Want fnr nddn'l info
FEE ITEMS (Fee Resolution 11-053 L' . 7/1'11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F-2507 ss.f.
$588.00
Remodel, Kitchen (<=300 sf)
IREMRESKIT
Suppl. PC Fee: E) Reg. ® OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
FT #
$26.00
Plumbing
IPRWHEATR Water Heater
Permit Fee:
$0.00
Suppl. Insp. Fee: Reg.
Q OT
0.0
hrs
$0.00
-17 # Mechanical
$130.00 IWR=<100 Furnace, Forced -Air
PME Unit Fee:
$0.00
PME Permit Fee:
$132.00
0 amps
$44.00
Electrical
1ERT<200 Services
Administrative Fee:
1ADMIN
$41.00
Q
Work Without Permit? Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
G
C
Travel Documentation Fee: 1TPA lrDOC
$44.00
Strong Motion Fee:
1BSEISM/CR
$2.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
1 $1.00
ilJ$TC... .. �
$220.00
$788.00
:�Q���1�: L:°.
$1,008.00
Revised: 1 /19/2012