12010098 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20510 TOWN CENTER LN CONTRACTOR:REHOBOTH PERMIT NO: 12010098
CONSTRUCTION GROUP
OWNER'S NANIE: CIVIC PARK CUPERTINO LLC 2785 LONGFORD DR DATE ISSUED:01/12/2012
OWNER'S PHONE: 4088969068 SAN JOSE,CA 95132 PHONE NO:(408)660-0040
L3
LICENSED CONTRACTOR'S DECLARATION CMN BUILDING PERMIT INFO: BLDG ELECT FPLUMB '
License Class I> Lie.# 17 � �iy� MECH 'mm
n ( i� RESIDENTIAL COMMERCIAL l
Contractor P� `-/� #�"4S��4e fes..`-.Date Vt Z
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TO CLEAR CODE ENFORECMENT CASE:REPLACE
(commencing with Section 7000)of Division 3 of the Business&Professions ELECTRIC
WATER HEATER
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
perfornrnrce 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 Sq.Ft Floor Area: Valuation:$300
permit is issued.
APPLICANT CERTIFICATION APN Number:36955082.20510 Occupancy Type:
I certify that 1 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
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,anti expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
r Issued byY nate:
Signature Date
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beiig installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
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
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
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
I certify that in the performance of the work for which this permit is issued,I shall trtaintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation law's of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or aetygrized agent: s
forthwith comply with such provisions or this permit shall be deemed revoked. Date: l Z—
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of wtxk's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnit}-and keep lrarniless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all nori-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
' I ADDRESS: 20510 town center In DATE: 01/12/2012 REVIEWED BY: bobs.
APN: BP#: VALUATION: $300 -�
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition /Repair
PRIMARY Commercial Building PENTAMATION PCWHEATR
hSE: PERMIT TYPE:
WORK To Clear Code Enforcement Case: Replace electric water heater.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PCWHEATR 1 # $26
TOTALS: $26.00
Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: IPPERMIT
0 Other Plumb Insp. 0.0 hrsl_L44.00 Lj L
1VOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are,based on the greliffina information available and are otdy an estimate. Contact the De t or addn't in o.
FEE ITEMS ;/e Res )l oil 11-t' h:I ' 1 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $26.00
PME Permit Fee: $44.00
Administrative Fee: ]ADMIN $41.00
Work/Without Permit? Ices Q No $70.00
Travel Documentation Fee: ITIN VDOC $44.00
Slro i2-Pv otion Fe--: 1BSEISAKC0 $0.50 Select an Administrative Item
r 'f;'s i ,Con-icnission Fee. IBCBSC $1.00
SUBTOTALS: $226.50 $0.00 TOTAL FEE: 1 $226.50
Revised: 1/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 26,f(o U,v% CN, PERMIT# t
OWNER'S NAME: PHONE# 4'CO? — u u "O
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: �$� 4,d r CITY/ZIPCODE: 'a►� - �fj�3z—_
*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. A
I am not using any subcontractors: /��
Signature Date
Please check applicable subcontractors and complete the following information:
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/Contractor Signature Date
I D ci .- (-) o (��l e
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
2 (408)777-3228• FAX(408)777-3333• building(cDcupertino.org MISC
CUPERTINO
❑PLUMBING ❑MECHANICAL []ELECTRICAL �SCEILANEOTJS �( �
PROJECT ADDRESS cf f'X-J J l vi A G� / A.PN# 3 (49
I ^9 6�f 0�ff 0 Q,
OWNER NANO q V ^ '-�` „/� PHONE 4 J�—�g�—�j,,/� E-MAIL
GteSTREET ADDRESS ` `f" (N / CITY, STATE,ZIP u' ` [ v C, / FAX
210A10
CONTACT NAME � PHONE /,_p Q G 9 J E-MAIL
STREET ADDRESS Jt/ CITY,STATE,`f3? U FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMEh L/ LICENSE NUMBER 3 LICENSE TYPE R BUS.LIC#
COMPANY NAME D n/� I r 1___j U EMAIL rjC C(C 0/ C FAX
STREET ADDRESS ,f f �✓ CITY,STATE ZIP ( v iQ �1 I L PHONE � O,
ARCHITECTIENGINEER NAME �d� t r` LICENSE NUMBER BUS.LIC#JQ o
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND❑' ❑ )F5 PROJECT IN ❑)'ES IS THE BLDG AN ❑ IJFS
BUILDING. COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLER HOME? NO
DESCRIPTION OF WORK
TOTAL VALUATION: 7� RECEIVED BY:
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.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 building cons tion`. `I authorize representatives of Cupertino to enter the above-identified property for inspection pu[poses.
Signature of ApplicandAgent: Date: I Z a✓
SUPPLEMENTAL INFORMATION REQUIRED OFFIc SE ONLY
m ° OVER-THE-COUNTER
❑ EXPRESS
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2
❑ STANDARD
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❑ LARGE
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❑ MAJOR
AEPMIscApp_2011.doc revised 06/21/11