12090156CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21165 HAZELBROOK DR
CONTRACTOR: ALL PHASE GENERAL
PERMIT NO: 12090156
CONSTRUCTION
OWNER'S NAME:
SAN JOSE, CA 95127
PHONE NO: (408) 603-0947
❑ LICENSED CONTRACTOR'S DECLARATION
F r— r
License Class Lic. #
BUILDING PERMIT INFO: BLDG ELECT PLUMB
v11Z
MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am license C per 9
JOB DESCRIPTION: REMODEL KITCHEN 205 SQ FT, M.BATH 87 SQ FT
(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 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: $35000
1 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
APN Number: 32628053.00
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
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
Issued by: //�i�/� �`7 �l/� Date:
9.18.
Signature Date
_1�2_4
RE -ROOFS:
❑ OWNER -BUILDER DECLARATION
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
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self -insure for Worker's
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
performance of the work for which this permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
[ certify that in the performance of the work for which this permit is issued, [ shall
not employ any person in any manner so as to become subject to the Worker's
w`n
Oor authorized agent:..
Compensation laws of California. If, after making this certificate of exemption, I
ou Date:'
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.
CONSTRUCTION AGENCY
I hereby affirm that there is a construction lending agency for the performance of wrk's
APPLICANT CERTIFICATION
for which this permit is issued (Sec. 3097, Civ C.)
I certify that I have read this application and state that the above information is
Lender's Name
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
Lender's Address
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
ARCHITECT'S DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Licensed Professional
Signature Date
FM-7
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21165 HAZELBROOK
DATE: 09/19/2012
REVIEWED BY: SYLVIA
APN:
BP#:
*VALUATION: $35,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1R3SFDREM
PERMIT TYPE:
WORK
REMODEL KITCHEN 205 SQ FT M.BATH 87 SQ FT
SCOPE
;Lfec%r. Plan Check
Plumb. Alan Cheek
C'lec. Plan Check
Flhfech. Permit Fees
Plumb. Permit Fee:
r/ec. Permiz FCe�
other Akch. 7n.vf".
O/ho- Plumb Insp,Li
U7berr Llec. Insp.
ilcch. lrasp. he<c:
Plumb. hwsA. sec<:
Glee. Insp. Fcze
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
Distric4 eta). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
87 s.f.
$600.00
Remodel, Bath (<=300 sf)
1REMRESBAT
Suppl. PC Fee: 0 Reg. C) OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
205 s.f.
$600.00
Remodel, Kitchen (<=300 sf)
IREMRESKIT
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0 p
firs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax. T7_
Administrative Fee:
Work Without Permit? 0 Yes (E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
i
Trope! Doctamentation Fees:
Strong Motion Fee: IBSEISMICR
$3.50
Select an Administrative Item
Bldp- Stds Commission Fee: IBCBSC
$2.001
SUBTOTALS:
$5.50
$1,200.00
_
TOTAI,ITE.-
$1,205.50
Revised: 07/01 /2012