12100215CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20791 SCOFIELD DR CONTRACTOR: PERMIT NO: 12100215
OWNER'S NAME:
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # 1
Contractor q � S10-0f ,'15 Date 10 - 3 f ' ® �
I hereby affirm that I 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
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 mention d property for inspection purposes. (We) agree to save
indemnify and keep hatless the City of Cupertino against liabilities, judgments,
costs, and expenses w,qc may accrue against said City in consequence of the
granting of this perms /additionally, the applicant understands and will comply
with all non -
Date la f blf
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, 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).
I 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.
BUILDING PERMIT INFO: BLDG J_ ELECT r PLUMB r-
MECH RESIDENTIAL COMMERCIAL r—
JOB DESCRIPTION: KITCHEN REMODEL(327 SQFT);REMOVE AND ENLARGE
KITCHEN WINDOW; CONSTRUCT 4 FT SHEAR WALL FOR
WINDOWS ENLARGEMENT
Sq. Ft Floor Area: I Valuation: $45000
APN Number: 35912004.00 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: s� (� /� Date: /U ��'%
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. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Codeection 25532(a) should I store or handle hazardous material.
Additional y,, sho ld I use equipment or devices which emit hazardous air
contamin n s aefined by the Bay Area Air Quality Management District I will
maintai c m "nance with the Cupertino Municipal Code, Chapter 9.12 and the
Health afity Code, Sections 25505, 25533, and 25534.
agent:
Date: fL,d
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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISIO
ADDRESS: 20791 Scofield Drive DATE: 10/31/2012 REVIEWED BY: Sean
APN: *VALUATION: $45,000
*PERMIT TYPE: Building PermiEEBP,#:
PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION 1 R3SFDREM
USE: SFD or Duplex PERMIT TYPE:
WORK Kitchen remodel 327 sq ft ; remove and enlarge kitchen window; construct 4 ft shear wall for window
SCOPE I enlargement.
NOTE: This estimate does not include fees aue to orner ueparemern- I—.
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'[ in o.
FEE ITEMS (Fee Resolution 11-053 Eff. 7111121 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 327 s.f. Remodel, Other
Suppl. PC Fee: (F) Reg. ® OT F0.0 1 hrs $0.00 $467.00 IREMRESOTH
PME Plan Check: $0.00 L—' J # Window / Sliding Glass Door
Permit Fee: $0.00 $799.00 1WINMEWSTR New (Shearwall/Masonry
Suppl. Insp. Fee:Q Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
$0.00
PME Permit Fee:
C'onstrric6on Tax
Ac1117irlistralive Fee:
Work Without Permit? Q Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential G
Building or Structure
A
Trarel Docuunenlei tinrr FCeS:
Strong Motion Fee: IBSEISMICR
$4.50
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
SUBTOTALS:
$2.00
' $6.50
$1,266.00 TOTAL FEE;
$1,272.50
Revised: 10/01 /2012