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11080155I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 11107 LINDA VISTA DR I CONSTR BOOR: ROSENTHAL I PERMIT NO: 11080155 OWNER'S 1 SAN JOSE, CA 95130 I PHONE NO: (408)249-1547 1 LICENSED CONTRACTOR'S DECLARATION License Class( Lic. # 7) C, ! & � 3 l Contractor. �gy yI T0 1 ms 4 ,Date f ( I 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: 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 th work for which this permit is issued. 1 have and will m:: main Worker's Compensation Insurance, as provided for by Section 3700 of tl., 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 kccp 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 0-4 ❑ ONN'NFR-BUILDER DECLARATION 1 hereby affirm a at I :un exempt from the Contractor's License Law for one of the following Iirn reasons: I, as owner of the roperty, or my employees with wages as their sole compensation, will do the work, ;.nd the structure is not intended or offered for sale (Sec.7044, Business & Profes<ions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Scc.7044, Business & Professions Code). 1 hereby affirm a nder 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 la%\ s 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 rend 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 kccp 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. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: ADD 118 SQ FT TO MASTER BEDROOM, REMODEL BATHROOM 290 SQ FT Sq. Ft Floor Area: I Valuation: $22000 APN Number: 35606019.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN % I E AYS OF PERMIT ISSUANCE OR 180 DAY OM LASTCALLED INSPECTION. Issued by: / ` - "L Date: RE -ROOFS: All roots 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 & Sa fely 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 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I lealth & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: 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 Address ARCHITECT'S DECLARATION Signature Date I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO Fm_� FEE ESTIMATOR - BUILDING DIVISION 1107 linda vista DATE: 08/19/2011 REVIEWED BY: bobs. NMIADDRESS: A.PN: BP#: "VALUATION: 1$22,000 %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Du lex USE: P god Unit? Yes No OTC? 0 Yes E)No PENTAMATION 1 R3SFDADD PERMIT TYPE: WORK I sfd add master bed remodel bath. 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,III-B,IV,V-B 118 VVS994.00 IADDPLCK $963.00 IADDINSP TOTALS: 1 118 $994.00 $963.00 MECH, HOURLY © Yes (F) No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY Q Yes Q No Li NOTE. These tees are based on the preliminary information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (lee Resolution 11-053 E . 74/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $994.00 290 s.f. $588.00 Remodel, Bath (<=300 sf) IREMRESBAT Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $963.00 Suppl. Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ( n+ittrtietion 1 ax Acoustical Fee: 0 Yes 0 No $0.00 Q Work Without Permit? 0 Yes (F) No $0.00 Planning Fee: PLLONGRNGR $15.34 Select a Non -Residential Building or Structure Q 0 i Travel Strong Motion Fee: IBSEISMCR $2.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1,975.54 $588.00 TOTAL FEE: $2,563.54 Revised: 07/04/2011