12020022CITY OF CUPERTINO BUILDING -PERMIT
BUILDING ADDRESS: 7626 NEWCASTLE DR CONTRACTOR: NADER SHAMMA PERMIT NO: 12020022
OWNER'S NAME:
CUPERTINO, CA 95014-5221 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION f— I—i
BUILDING PERMIT INFO; BLDG ELECT PLUMB
License Class Lic. #
MECH RESIDENTIAL f— COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: TWO(2)BATHROOM REMODELS, I 56SQFT
(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 (lie 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 Unis permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature
Date
Sq. Ft Floor Area: I Valuation: $7500
APN Number: 36617084.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 D YS FROM ST CALLED INSPECTION.
Issued by: �� Date:
`/ 2--
'I
I hereby affirm under penalty of perjury one of the following three
declarations:
l 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 regulation per the Cupertino Municipal Code, Section
9.18. /Zl'1
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. 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 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.
N
, ��
CONSTRUCTION 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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Date :P /;k,
��,�---� CITY OF CUPERTINO
Ill FEE ESTIMATOR - BUILDING DIVISION
iA1ADDRESS:
7626 Newcastle Drive
DATE: 02/06/2012
REVIEWED BY: larry s
A_PN: (,9 eLYVI
BP#: 0 a
"VALUATION: 1$7,500
°PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
bathrooms 2 remodel 156 s . ft. total
SCOPE
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nrelininary information availahle and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (F'ee Resolution 11-053I f. 7/T-11 j
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
156 s.f.
$588.00
Remodel, Bath (<=300 sf)
IREMRESBAT
Suppl. PC Fee: Q Reg. 0 OT
0.0 1
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
SuppL Insp. Fee-0 Reg.
Q OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
77
0
G
Work Without Permit? ® Yes (F) No
$0.00
Advanced Plannine Fee:
$0.00
Select a Non -Residential
Building or Structure
0
Strong Motion Fee:
IBSEISMICR
$0.75
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.75
$588.00
TOTAL FEE:
1 $589.75
Revised: 111912012