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12010053 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10965 MIRAMONTE RD CONTRACTOR:TBD-TO BE DEi(ERMINED PERMIT NO: 12010053 OWNER'S NAME: LYNN&MIKI YOUNGS DATE ISSUED:01/06/2012 OWNER'S PHONE: 4082530752 PHONT NO: 091, LICENSED CONTRACTOR'S DECLARATION � r- �,�y BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class _ Lic.# d 8 (� r_ f / MECH RESIDENTIAL COMMERCIAL Contractor Pry/!/sJZ2L[•p_G''S' Date I hereby affirm that 1 am licensed under the provE#ions/of Chapter 9 JOB DESCRIPTION:ADD NEW GAS LINE FROM METERTO BEDROOM, (commencing with Section 7000)of Division 3 of the Business&Professions INSTALL Code and that m license is in full force and effect. FREE STANDING GAS DIRECT VENT FIREPLACF.AND y VENTING PAINT VENT CAPS. 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. 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. Sq. Ft Floor Area: Valuation:$2700 APPLI('AN'I'CER7'IFICA7'ION I certify that I have read this application and state that the above information is APN Number:35601032.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9 18. Signature Datc Issued by: ��' %� � Dater c/, ❑ OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered lir sale(Sec.7044, inspection. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to Signature ol'Applicanl Date. construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to sell'insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 1 have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Section 3700 of the Labor Code,for the performance ofthe work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should 1 store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If;after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the labor Code,1 must forthwith comply with such provisions or this permit shall be deemed revoked. Ow r r utho ' went Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting ofthis permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ARC111TECT'S DECLARATION I understand my plans shall be used as public records. Signature Date Licensed Professional Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: j , ?'(Or PERMIT# 0115 J OWNER'S NAME: ` PHONE# ZS3 GENERAL CONTRA TOR: BUSINESS LICENSE# ADDRESS: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. �, I am not using any subcontractors: ` Z Signatu Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum/Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 01 2�z� 1/�/ 2- Owner/ ntractor Signature �7 Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10965 miramonte rd. DATE: 01/06/2012 REVIEWED BY: bobs. APN: ' S Q a BP#: �D .S3 "VALUATION: 1$2,700 }PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Du lex PENTAMATION FURN/AC USE: p PERMIT TYPE: WORK add new gas line install free standing direct vent fireplace. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Heating Appliance 1MRRAA 1 # $65 TOTALS: $65.00 Mech.Plan Check0.0 hrs $0.00 I F Mech.Permit Fee: 1MPERMIT Other Mech.Insp. 0.0 hrs $44.00 Li NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These ees are based on the relinina in ormation available and are onl an estimate. Contact the De t or addn 11 info. FEE ITEMS (1-'ee Resolution 11-053 Etf 1./lli FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? Yes (F) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bld S`tds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $195.50 $0.00 TOTAL FEE: $195.50 Revised: 1/01/2012 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• building(acupertino.org ,/J� MISC CUPERTINO /�� '�✓� PLUMBING MECHANICAL ❑ELECTRICAL MISCELLANEOUS PROAD RESS AFN# 9 �7 t/)/ / 03 O NAME PHONE 2_5-s-o7,5-T7 E-MAIL S STREET ADDRESS CITY, STATE,ZIP �y FAX vl CONTACT NAME HONE-77m A�&Ak, kz),!Z Z,6 STREET ADDRESS CITY, TT ZIP FAX ❑OWNER ❑ OwNER-BUILDER ❑ OWNER AGENT 19 CONTRACTOR ❑CONTRACTOR AGENT 13ARCHITECT 1:1ENGINEER ❑ DEVELOPER ❑ TEN TRANT CTCO CTOR N I1 �jIV MBER LIE TYPE BUS.LIC#a , /` `�� COIr NAME E r + � FAX � C S ADD SS C ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF A SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA jo NO FLOOD ZONE NO EICHLER HOME? IRNO DESCRIPTION OF WORK ,0i1° Y- Oe �= 7: A TOTAL VALUATION: d 2c 7 RECEIVED BY: f By my signature below,I 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 I have provided is correct. �i have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin;to ilding constructio I authorize r S tatives of Cupertino to enter the above-identified property for inspection pulposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFO N REQUIRED OFFICE USE ONLY W O -OVER-THE-COUNTER r ❑ EXPRESS U W ❑ STANDARD U ❑ LARGE ❑ MAJOR 1EPMiscApp_2011.doc revised 06/21/11