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12010095
CITY OF CUPF.RTINO BUILDING PERMIT BUILDING ADDRESS: 10181 FINCH AVE CONTRAC'uOR: BENJAMIN PERMIT NO: 12010095 FRANKLIN PLUMBING OWNER'S NAME: BETHEL LUTHERAN CHURCH PO BOX 1072 DATE ISSUED:01/12/2012 OWNER'S PHONE: 4082528500 CAMPBELL, CA 95009 PHONE NO:(408)298-1776 LICENSED CONTRACT'OR'S DECLARATION �- Bl'II,DING YF,12N117'INFO: I31.DG F,LF:C"1'' PLUMBLicense Class C 14 L3ic.# S 7 \IECII RESIDENTIAL CO.I'VIERCIAL Contractorto Z" I Z JOB DESCRIPTION: REPAIR GAS LINE;AT COMM BUILDING 1 hereby affirm that 1 am �ndervisions of Chapter (commencing with Se 000)of Division 3 ofthe Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one ofthe following two declarations: I have and will maintain a certificate of consent to sell'insure for Worker's Compensation,as provided for by Section 3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. Sq. Et Floor Area: Valuation:SI X83 1 have and will maintain Workers Compensation Insurance.as provided for by Section 3700 ofthe Labor Code,for the performance of the%\url: for whi ti s U N Number:3750302_00 Occupancy Type: permit is issued. AITLICAN I'CE:R"IIFICATION I certify that I have read this application and state that the above it ormation PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state lawslatin`a WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspct:uun purposes. (We)agree to save 180 DAY F M LAST CALLF,D INSPEC"I'IO indcmnily and keep harmless the City ofCupertino against liabilities,jud-ments, costs,and expenses which nvty accrue against said City in consequence ofthe granting of this pernia. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature bate 11-14 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. ❑ OWNER-13CILDE:R DECLARATION 5111,1IalUre of Applicant.— bate: I hereby affirm that 1 am exempt from the Contractor's License Lai+ for one of the following two reasons: kLI,ROOF COVERINGS TO 13E CLASS"A" OR BETITR I,as owner ofthe 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 70-14. Business&Professions Code) I-as owner ofthe property,am cxclusivcly contracting with licensed contractor;to 11AZARDOIS MATERIALS DISCLOSIRE. construct the project(Sec.704,1.Business&Professions('ode)- I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjtn-y one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Ilealth&Safety Code,Section 25532(a)should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Workers material. additionally,should 1 use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 ofthe Labor Code,for the air contaminants as defined by the Bay Arca Air Quality Management District performance ofthe work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections 25505,25533,and 25534 Section 3700 ofthe Labor Code,for the performance ofthe work for which this y r or authorized agen _ Date:�� )q permit is issued. I certify that in the perlormance ofthe 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,alter makinu this certificate ofexemption. I CONS"1'R[C'CION LENDING AGENCY become subject to the Worker's Compensation provisions ofthe Labor Code. I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked work's for x0ich this permit IS issued(Sec-3097,Civ C) Lender's Namc APPLICANT CERTI FIC.VI'I0N Lender's address I certify that I have read this application and state that the above infornauon is correct. I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representati\cs of this cit) to enter upon the above mentioned property for inspection purposes.(WO agree to sm c indemnify and keep harmless the City ol'Cupertino against liabilities.judgments- 112CI11"hEC"I"S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the I understand my plans shall bC used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code.Section Licensed Professional _ 9.18. Signature_ Date_ 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: I i j C PERMIT# OWNER'S NAME: C7H A- Lv t-}6jZAj ulz- PHONE# SUS GENERAL CONTRACTOR: C�J A-�-JW BUSINESS LICENSE# ADDRESS: Z2 hI7lrt_ gZ 7E 0,4 E CITY/ZIPCODE: Aj c4j ,6710 A. *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 OBJWNED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: // � Signat a Date Please check applicable subcontractors ainTcormplete 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 Owner ontractor Signature Date CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp : Rng: Sub: Blk: Lot : APN . . . . . . . . : 37503022 . 00 DATE ISSUED. . . . . . . : 01/12/2012 RECEIPT # . . . . . . . . . : BS000015746 REFERENCE ID # . . . : 12010095 SITE ADDRESS . . . . . : 10181 FINCH AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER BETHEL LUTHERAN CHURCH ADDRESS 10181 FINCH AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3410 RECEIVED FROM . . . . : BRAD RICKARD CONTRACTOR . . . . . . . : CHAD NELSON LIC # 28520 COMPANY BENJAMIN FRANKLIN PLUMBING ADDRESS PO BOX 1072 CITY/STATE/ZIP . . . CAMPBELL, CA 95009 TELEPHONE (408) 298-1776 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 1 , 583 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICO VALUATION 1 , 583 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1BUSLIC FLAT RATE 1 . 00 119 . 00 0 . 00 119 . 00 0 . 00 1PGASRES OUTLETS 1 . 00 65 . 00 0 . 00 65 . 00 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 314 . 5f� 0 . 00 314 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ------------- ---- ----- -- --- --- -- -- ------ ------ - -- --- CREDIT CARD 314 . 50 visa - -- -- -- -- -- --- - TOTAL RECEIPT 314 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR BUILDING DIVISION ADDRESS: 10181 Finch ave REVIEWED BY: sylvia DATE: 01/12/2012 PE�I—yj- APN: P#: VALUATION: 1$1,583 A PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/Repair PENTAMATION 1 CPGAS PRIMARY Commercial Building PERMIT TYPE: USE: WORK REPAIR GAS LINE AT COMM BUILDING SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $65 TOTALS: $65.00] EjPlumb.Plan Check $0.00 Plumb.Permit Fee: IPPERWT Other Plumb Insp. L hrs L_!44.0 L-O I _01 NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These Lees are based on theprelin"dina information available and are o!&an estimate. Contact the Dept,Lor addnl info. I I Llf-r 7 111 �C ITEMS 11 -R Q, FEE ITEMS,.','.,e, esoivlion 1 L( FEE A PME Plan Check: $0.00 PNIE Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: JADMIN $41.00 Work Without Permit? Yes (j) No $0.00 Travel Documentation Fee: I TRA VDOC $44.00 '1010bio'--Fe-1: IBSEISAKC0 $0.50 Select an Administrative Item Fee� n IBCBSC $1.00 SUBTOTALS: $195.501 $0.00 TOTAL FEE: $195:5.50 Revised: 1/01/2012 141'7 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE -CUPERTINO, CA 95014-3255 Lo (408)777-3228 • FAX(408)777-3333- building(a.cupertino.org MISC CUPERTINO 190 l do q 6"_ ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS ,0 L C- Aic �N# 0:a a, OWNER NAME PHONE E-MAIL (3 E i N"A L- <-� CR G" `1 c�-f f?Q Z Z S c� STREET ADDRESS CITY, STATE,ZIP FAX C) ! F1 ',)Ll Gv?c-jZ.7 r,Jn 11 c/4 CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGE 4T ACONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑m4mN ER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LI SE NUMBER LICENSEBUS.LIC# COMPANY NAME E-MAIL FAX A wl, i �,Jk�(,J El,LIV41 I,J-" .415 , L/5,7' 3Z0,7 STREET ADDRESS CITY,STATE,ZIP PHONE --z T)1I✓I7,L ©.JE til 00/t-IE) c 4 . 14T y15 . L154 75c�n ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMMY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK - 2" ^,-> lac AT 14C TOTAL VALUATION: 5 RECEIVED BY: By my signature below,I certifj 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.j 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 buildin construction."I authorize representatives of Cupertino to enter the above-identified property for inspection pudposes. Signature of Applicant/Agent Date: ,-z-/n SUPPL INFORMATION REQUIRED CkMCE USE ONLY OVER-THE-COUNTER ❑ EXPRESS U W ❑ STANDARD U ❑ LARGE a ❑ MAJOR MEPMiscApp 2011.doc revised 06/21/11