12010152CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 795 ALDERBROOK LN
OWNER'S NAME:
Ga/LICENSED CONTRACTOR'S DECLARATION
License Class Li,. # F / 3 Z-
Contractor KG�v.(_ Date RJR L
l hereby affirm that l 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 by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
1 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. Add' ionally, the applicant understands and will comply
with all non - Municipal Code, Section
9.18.
Signature Date ( L Z
❑ OWNER -BUILDER DECLARATION
l 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 tinder penalty of perjury one of the following three
declarations:
1 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.
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.
1 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, 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.
CONTRACTOR: EMPIRE FLOORING & PERMIT NO: 12010152
DESIGN CENTER
495 E BROKAW RD DATE ISSUED: 01/25/2012
SAN JOSE, CA 95112 PHONE NO: (408) 20-0996
BUILDING PERMIT INFO: BLDG I— ELECT PLUMB f—
MECH ' RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: SINGLE FAMILY DWELLING BATHROOM REMODEL(IST
FLOOR)65SQFT,NON-STRUCTURAL AND REPLACE EIGHT(8)
W INDOW S,NON-STRUCTURAL
Sq. Ft Floor Area: I Valuation: $13000
APN Number: 36916013.00 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:�7 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. 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 witn)the Cupertino Municipal Code, Chapter 9.12 and the
Health & SafetyXode, S&tions 25505, 25533, and 25534.
Owner
LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of mrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Add
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records.
'2
Signature Date I Licensed Professional
AEVISION #
CITY OF CUPERTINO BUILDING PERMIT DATE
BUILDING ADDRESS: 795 ALDERBROOK LN
CONTRACTOR: EMPIRE FLOORING &
PERMIT NO: 12010152
DESIGN CENTER
OWNER'S NAME:
SAN JOSE, CA 95112
PHONE NO: (408) 213-09%
❑ LICENSED CONTRACTOR'S DECLARATION
[� r
'
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class, G/r' Lic. # q
r r
MECH RESYDENTT�1L COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: SINGLE FAMILY DWELLING BATHROOM REMODEL(IST
(commencing with Section 7000) of Division 3 of the Business & Professions
ON -STRUCTURAL AND REPLACE E[GHT(8)
Code and that my license is in full force and effect.
WINDOFLOOR)65 ,NON-
WINDO W S,NON-STRUCTURAL
2/21/2012 - REV# I - REVISE ROOF FRAMING OVER KITCHEN AREA -REV# I [SS'D
l hereby affirm under penalty of perjury one of the following two declarations:
2/21/2012
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
Sq. Ft Floor Area:
Valuation: $13000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 36916013.00
Occupancy Type:
[ certify that 1 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,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may acc against said City in consequence of the
granting of this permit. Additional , the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non -point sour regular' per the Cupertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signatur Date~��
)
Issued by: Dater 2 /
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I, as owner of the property, or my employees with wages as their sole compensation,
installed without first obtaining an inspection, I agree to remove all new materials for
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. l will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
l certify that in the performance of the work for which this permit is issued, I shall
contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, I
Health & Safe Code, Sections 25505, 25533, and 25534.
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.
:
Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
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
1 hereby affirm that there is a construction lending agency for the performance of work's
to building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (Sec. 3097, Civ C.)
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Lender's Address
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
RF��,�--�� CITY OF CUPERTINO
%72 FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 795 alderbrook In.
DATE: 01/25/2012
REVIEWED BY: bobs.
APN: ZIP a/
BP#: /07(��d S-
"VALUATION: 1$13,000
'PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
sfd bath 1 story remodel non structural replace 8 windows non structural.
SCOPE
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta ). These fees are based on the nrelimnary Informatinn available and are anly an estimate. Cnntact the Dent far addn'l infix
FEE ITEMS (Fee Resolution 11-053 E' . 711;11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F__657 s.f.
$588.00
Remodel, Bath (<=300 so
IREMRESBAT
Suppl. PC Fee: E) Reg. 0 OT
0.0 1
hrs
$0.00
PME Plan Check:
$0.00
F 8-1 #
$392.00
Window / Sliding Glass Door
IWINREP Replacement
Permit Fee:
$0.00
Suppl. Insp. Fee.S Reg.
Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Work Without Permit? Q Yes (D No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
G
„# ,: j .: ,
Strom Motion Fee:
IBSEISMICR
$1.30
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
1 $1.00
SUBTOTALS:
1 $2.301
$980.001
TOTAL FEE,
$982,30
Revised: 1 /19/2012
{{,,''�---��CITY OF CUPERTINO
-W FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 795 alderbrook In.
DATE: 02/21/2012
REVIEWED BY: bobs.
APN: 16 O -3
1 BP#: 12010152
"VALUATION: Iso
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 GENRES
PERMIT TYPE:
WORK
revise roof framing over kitchen area.
SCOPE
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
WviricL ofc )_ Thavo foov or.- hncod nn Iho nrolininary infarmafinn availahlo and ara nnly an acfimnlo_ rantnet Iho Dom far addn'I info_
FEE ITEMS (1'ee Resolution 11-053 E . 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? Q Yes ® No
$0.00
717 hours Plan Check, Hourly
$130.00 ISTPLNCK
Suppl. PC Fee: Q Reg. () OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee.S Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
Work Without Permit? ® Yes (D No
$0.00
Advanced Planning Fec:
$0.00
Select a Non -Residential
Building or Structure
$
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.001
$130.00 TOTAL FEE:
$130.00
Revised: 1 /19/2012