12010156CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11223 PALOS VERDES CT
CONTRACTOR: REBOZZI INC
PERMIT NO: 12010156
OWNER'S NAME:
SAN JOSE, CA 95M
PHONE NO: (408)229-9689
99 LICENSED CONTRACTOR'S DECLARATION
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License Class Lie. # l Iq 773
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH � RESIDENTIAL l COMMERCIAL �W
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Contractor ZS Ce�yy.A� �B�te — Z
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I hereby affirm that I am licensed under the provisions of Chapter
JOB DESCRIPTION: SINGLE FAMILY DWELL 16SQFT KITCHEN REMODEL,
(commencing with Section 7000) of Division 3 of the Business & Professions
I08SQFT LAUNDRY REMODEL, REPLACE TWO(2)WINDOWS;
Code and that my license is in full force and effect.
MINOR STRUCTURAL
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
Sq. Ft Floor Area:
Valuation: $75000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 35621026.00
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, a applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulation p e Cupertino Municipal Code, Section
9.18.
Signat Date1 Z7 �2
Issued by:- Date:
a
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
[ 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
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health & Safety Code, cti s 25505, 25533, and 25534.
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
Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
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APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
1 hereby affirm that there is a construction lending agency for the performance of mrk's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
with all non -point source regulations per the Cupertino Municipal Code, Section
9,18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
� �� CITY OF CUPERTINO
1-1 FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 11223 palos verdes ct.
DATE: 01/25/2012
REVIEWED BY: bobs.
APN: D Z(a
1 BP#: /-Z b/O S 61
"VALUATION: 1$75,000
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK I
sfd 162 s.f. kitchen 108 laundry remodel replace 2 windows minor structural
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 nrelinrnary information available and are only an astinmte- Contact the Dent for addn'1 info.
FEE ITEMS (free 12esolution 11-053 Ef/. 71/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
162 s.f.
$588.00
Remodel, Kitchen (<=300 so
IREMRESKIT
Suppl. PC Fee: D Reg. Q OT
Q.Q
hrs
$0.00
PME Plan Check:
$0.00
1-0 87 s.f.
$588.00
Remodel, Bath (<=300 so
IREMRESBAT
Permit Fee:
$0.00
SuppL Insp. Fee-.0 Reg.
Q OT
0
hrs
$0.00
2 # Window / Sliding Glass Door
$392.00 1WINREP Replacement
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
T-F
0
G
Work Without Permit? Yes No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
G
Strong Motion Fee:
IBSEISMICR
$7.50
Select an Administrative Item
BldgStds Commission Fee: 1BCBSC
$3.00
SUBTOTALS:
$10.50
$1,568.00
TOTAL FEE:
F$1,578.50
Revised: 1119/2012