12030039CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10942 NORTHSEAL SQ CONTRACTOR: MADHURA TARE PERMIT NO: 12030039
OWNER'S NAME:
CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION F_
BUILDING PERMIT INFO: 13LDG ELECT PLUMB
License Class Lic.N 1— J— r
iN9ECII RESIDENTIAL COMMERCIAL
Contractor
Date
1 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 hvo 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
9.19.
Signature _ Date
OWNER -BUILDER DECLARATION
1 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 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
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 ( ovD 20
JOB DESCRIPTION: REMODEL BATH 64 SQ FT, CONSTRUCTINTERIOR
PARTIITION AT LIVTNG/DINING AREA TO CREATE
DEN/BEDROOM
Sq. Ft Floor Area: I Valuation: $13500
APN Number: 31640026.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by1 Date: 34. / rL
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. Il'a rooris
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Appli
Date:
ALL ROOF COVERINGS TO BE CLASS "A" Oil BET-FER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 695 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 1 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 1
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, Q I
r or authorized agent: Date: O v" �!
CONSTRUCTION LENDING AGF,NCY
I hereby affirm that there is a construction lending agency for the perl'onnance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Ad
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FMON FEE ESTIMATOR - BUILDING DIVISION
igADDRESS:
DATE: 3-f -1 I—
I REVIEWED BY:
APN: 3 /� �fp pa (
BP#: aQ c/
"VALUATION:
1$13.400
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1GENRES
PERMIT TYPE:
wORK
Bathroom remodel 64 sq ftand construct interior patition at living/diningliving/dining to create den/bedroom.
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 preiininary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee 12esolution 11-053 Ejf T'1/11)
FEE
QTY/FEE
- MISC ITEMS
Plan Check Fee:
$0.00
10 If
$457.00
Interior Partitions
IPARTIR<=30
Suppl. PC Fee: Q Reg. 0 OT
0.0 1
hrs
$0.00
PME Plan Check:
$0.00
64 s.f.
$588.00
Remodel, Bath (<=300 so
IREMRESBAT
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg.
Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Work Without Permit? ® Yes (j) No
$0.00
Advanced Plannine Pee:
$0.00
Select a Non -Residential
Building or Structure
Stron(_1 Motion Fee:
IBSEISMICR
$1.35
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2.35
$1,045.00
'TOTAL FEE:
1 $1,047.35
Revised: 1 /19/2012