11110176 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10228 MIRA VISTA AVE CONTRACTOR:BATH FITTER NORTHERN PERMIT NO: 11110176
CALIFORNIA
OWNER'S NAME: VERNON WILLIAM F 3 AND BILLIE 2118 ZANKER RD DATE ISSUED: 11/30/2011
,.,/ER'S PHONE: 4082572947 SAN JOSE,CA 95133 PHONE NO:(409)834-1111
1y LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB -
License Class e 3�o Lic.4 703 -5 -73 MECH r RESIDENTIAL r COMMERCIAL r
Contrac A. ate
I hereby afffrm that 1 am licensed under the rovisions of Chapter 9 JOB DESCRIPTION: INSTALL NEW SHOWER VALVE
(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. Sq.Ft Floor Area: Valuation:$945
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:35702029.00 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 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 consequence
of
judgments, 180 D S FROMLW
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-poin source regulations per the Cupertino Municipal Code,Section Issued by: J Date:
9.18. ! D
9 30 /
Signature Date ��
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material beitg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,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 1 will
permit is issued. maintai compliance with the Cupertino Municipal Code,Chapter 9.12 and the
HealtM1 S fe Code,Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this pemtit is issued,I shell
not employ any person in any manner so as to become subject to the Worker's Ow r r
Compensation laws of California. If,after making this cerlificate of exemption,I 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. rl CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work'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.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 Lender's Address
upon the above mentioned property for inspection purposes,(We)agree to save
to and keep harmless the Cityof Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
g ting 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
• CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35702029. 00
DATE ISSUED. . . . . . . : 11/30/2011
RECEIPT #. . . . . . . . . : BS000015446
REFERENCE ID # • . . : 11110176
SITE ADDRESS . . . . . : 10228 MIRA VISTA AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : VERNON WILLIAM F 3 AND BILLIE
ADDRESS . . . . . . . . . . : 10228 MIRA VISTA AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2705
RECEIVED FROM . . . . : JOE NANNETTI
CONTRACTOR . . . . . . . : BATH FITTER NORTHERN CALIFORNI LIC # 31358
COMPANY . . . . . . . . . . : BATH FITTER NORTHERN CALIFORNI
ADDRESS . . . . . . . . . . : 2118 ZANKER RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE . . . . . . . . : (408) 834-1111
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1.00 41. 00 0 .00 41. 00 0. 00
1BCBSC VALUATION 945.00 1. 00 0.00 1.00 0. 00
1BPFIXTURE NO OF FIXTURE 1. 00 9. 00 0. 00 9.00 0.00
1BSEISMICR VALUATION 945 .00 0.50 0. 00 0 .50 0.00
1PPERMITFE FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0 .00
1TRAVDOC FLAT RATE 1 .00 44 . 00 0.00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 139.50 0 . 00 139.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 139.50 VISA
---------------
TOTAL RECEIPT 139.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING 512 FINAL HANDI-CAP
•
GENERAL PERMIT APPLICATION
( I / / `' ` ' MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 I
SC
(408)777-3228• FAX (408) 777-3333• buildino2Dcupertino.ora
�UPERTINO
PLUMrBIING // MECHANICAL ELECTRICAL MISCELLANEOUS
PR 1 T DD /V'S / )'P— V IS MA
O APNN r , \Z__ C)�
41
OWNER NAME I p of _�� ^ E-MAIL
STOD SS k� % b ,S TE, P N0 O( ,-r / FAX
ETAD
CONTACT NAME _ PHOW / (�E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICE U B ^ LIC S PE BUS.LIC#
C ANY NAME E-MAIL V� FA TIO _(�-O(, /r�
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STREET DRESS TY,ST TE, IP 46,9 -6--N
s c 05-I'S -6
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
OF ❑SFD ar DUPLEX ❑ MULTI-FAMILY PROTECT IN WILDLAND ❑ YES PROTECT IN ❑ YES IS THE BLDG AN ❑ YES
DING', ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK 1n ' ^�^y—'
V v UI 1
TOTAL VALUATION: RECEIVFDBY,i
~r
By my signalum below,[certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information 1 have provided is cortect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. 1 authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED -OF'
FICE USE ONLY '
�li 'prw`� ❑ 'OVER-THE-COUNTER
❑ EXPRESS "
:L
I� �' " i❑ STANDARD
3 ❑ LARGE
is 6 a
it1❑ MAJOR' . 'f{
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
• ADDRESS: 10228 mira vista road DATE: 11/30/2011 REVIEWED BY: larry s
APN: BP#: "VALUATION: $945
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPFIX
USE: PERMIT TYPE:
WORK install new shower valve
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixture or Trap 1BPFIXTURE 1 # $9
TOTALS: - $9.00
Merin. 111m,Chock Plumb.Plan Check 0.0 his $0.00 Elec.1'fron Chick
ma;h- Pferw n Fes: Plumb.Permit Fee: IPPERMIT Chet, Pernnh Fare:
Uthrr,14c,4.htsl:. Other Plumb Insp. 0.0 his $44.00 puna E1ec. uup. El
Meth.In,Vn Fee: Pluu,l:. Irup.i-er: lilec.Invi, Pee:
NOTE: This estimate does not Include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prellndna In ormadon available and are only an estimate. Contact the De t or addn7info.
FEE ITEMS (Fee Resolution 11-053 LI. 7/1/1 U FEE QTY/FEE MISC ITEMS
Plan Check Fac:
Sapp[ PC P ce
PME Plan Check: $0.00
Pernnit Fee:
Supp/. htsp Fee
PME Unit Fee: $9.00
PME Permit Fee: $44.00
Construction 'lira
Administrative Fee: (ADMIN $41.00
Work Without Permit? Yes (F) No $0.00
,4,111MWC Planning fees:
Travel Documentation Fee: ITRAVDOC $44.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
• Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS, $139.50 $0.00 I,, TOTAL FEE: $139.50
Revised: 10/01/2011