12050153CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21731 SANTA BELLA PL
CONTRACTOR: KINNUNE RICHTER F AND
PERMIT NO: 12050153
BARBARA
OWNER'S NAME:
CUPERTINO, CA 950144833
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
F
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
F
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: KITCHEN REMODEL 200 SQ FT & UPGRADE SERVICE
(commencing with Section 7000) of Division 3 of the Business & Professions
PANEL
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.
Sq. Ft Floor Area:
Valuation: $1000
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.
APN Number: 35622022.00
Occupancy Type:
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
correct. 1 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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FROM LAST CALLED INSPECTION.
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,
Issu Date:�2�1.
Signature Date
OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, 1 agree to remove all new materials for
the following two reasons:
inspection.
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,
Signature of Applicant: Date:
Business & Professions Code)
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:
HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued, I shall
Health & Safety Code, Sections 25505, 25533, and 25534.
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
authorized agent:
�
become subject to the Worker's Compensation provisions of the Labor Code, I m st
/
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of Hork's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
ARCHITECT'S DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9. 18.
Licensed Professional
Signature �/ Date :y 1
!
CITY OF CUPERTINO
W-0 FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 23731 Santa Bella PI
DATE: 05/21/2012
REVIEWED BY: Sean
IMN
APN:
I BP#:
°VALUATION: $10,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1R3SFDRE
PERMIT TYPE: i
WORK
Kitchen remodel 200 sq ft
SCOPE
!'fan Che,
PhIlub. Platl FT_
7 _—..._-- C- -�.:1
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P"w ,. , 1 , ,..
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(nher.NfivFs.Ir":p.
OehevPlumbIt-;:Li
Orr'i�� i:';:C. hisp.
I c '
Plumb. lu.y. Fee,
r.r: f� s� rec:
NOTE: This estimate does not inchide fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution II-053 Eff 7/I/II)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F200 s.f.
$588.00
Remodel, Kitchen (<=300 sf)
IREMRESKIT
Suppl. PC Fee: 0 Reg. 0 OT
0.0
firs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee-0 Reg. 0 OT
F0,0Thrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Imi'liction 717x:
rurti.clrrrfitt f ecr:
0
0
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
i
7i,rtel Dokvtnr:n(ulion Fees,:
Strong Motion Fee: IBSEISMICR
BldgStds Commission Fee: IBCBSC
$1.00
$1.00
(�i�
Select an AdministrJp Item L1.1
SUBTOTALS:
1 $2.00
$588.00
TOTAL FEE:
1$
0.00
Revised:X4/01/2012