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12010151 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 1018I FINCH AVE CONTRACTOR:BENJAMIN FRANKLIN PERMIT NO: 12010151 PLUMBING OWNER'S NAME: BETHEL LUTHERAN CHURCH PO BOX 1072 DATE ISSUED:61/25/2012 OWNER'S PHONE: 4082528500 CAMPBELL,CA 95009 PHONE NO:(408)298-1776 INCENSED CONTRACTOR'S DECLARATION µ tT BUILDING PERMIT INFO: BLDG ELECT ' PLUMB License Class C34 _ Lic.# �1 S? 3,s; 7 R'I ��._ ;.m _ ECH � RESIDENTIAL COMMERCIAL 2 , Contractor z) �I j R m�1 FA ni4-1 r 4 Date 1 2 I Z— I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE 200L.F. I l/2'DIAGONAL GAS LINE FROM (commencing with Section 7000)of Division 3 of the Business&Professions METER TO PRE-SCHOOL BUILDING 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$5000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. AFN Number:3750302.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section '� 9.18. Issued b�✓ d Date:/ �J—� Signature Date �'S ❑ � -BUII_�DER IIECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,or nay employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See.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 HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air Section 3"700 of the Labor Code,for the performance of the work for which this contamivants 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 I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owner or auth become subject to the Worker's Compensation provisions of the Labor Code,I must _Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of wcxk's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnity 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 with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plaits shall be used as public records. 9.18. Licensed Professional Sianature 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: 1 6/JGrt /0 F PERMIT OWNER'S NAME: Lv PHONE# L/ Z 2' S CYO GENERAL CONTRACTOR:3E'^JJ7AY4b-J J'72AA/kN.�J BUSINESS LICENSE# ADDRESS:?--2—'0161 -trL P►Z S7f- Q. f I CITY/ZIPCODE: L),t--70 CA. ?49g9 *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' ure 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 1 / z5/1 er actor Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37503022 . 00 DATE ISSUED. . . . . . . : 01/25/2012 RECEIPT #. . . . . . . . . BS000015833 REFERENCE ID # . . . : 12010151 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 . . . . : PERMIT SERVICES INC 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 5, 000 .00 1. 00 0 . 00 1 .00 0 .00 1BSEISMICO VALUATION 5, 000 .00 1.05 0 . 00 1.05 0.00 1PGASCOM 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 196. 05 0 .00 196 .05 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 196 . 05 #3364 --------------- TOTAL RECEIPT 196. 05 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. DATE: 01/25/2012 REVIEWED BY: bobs. APN: BP#: VALUATION; 1$5,000 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY Commercial Building PENTAMATION 1CPGAS USE: PERMIT TYPE: WORK replace 200 11 11/2'dia. gas lione from meter to preschool building SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASR 1 # $65 TOTALS: $65.00 Plumb.Platt Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT ILIl Other Plumb Insp. 0.0 hrs $44.00 NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These,Lees are based on the Prelinina in ormation available and are onl an estimate. Contact the De, t or addn't in o. FEE ITEMS f a:$ft at II- ' *:' .."1 11,i FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit:' 0 Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 3Ll11-1l�.?11' ,((11 n �'�:'.;;I IBSELS'MICO $1.05 Select an Administrative Item IBcasC $1.00 SUBTOTALS: $196.051 $0.00 TOTAL FEE: $196.05 Revised: 1/19/2012 GENERAL PERMIT APPLICATION MEP [is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC CUPERTI Nth (408)777-3228•FAX(408)777-3333•building(cDcugertino.org PLUMBING MECHANICAL ELECTRICAL Fj MISCELLANEOUS PROJECT ADDRESS /^� � ) Ad APN# / �► j OW ER NAS ` LU`( C_g R j 1.12 CN PHONE E-MAIL STREET ADDRESS CITY, STATE,ZIP FAX O CONTACT NAME �� '� ` PHONE /D +.1 `�O E-MAIL STREET ADDRESS CITY,STATE,ZIP t�C ter FAX _ ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR $I CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# �, A 12 ,J i�u ' '+�J,N►31 N' 5 7 357 C COMPANY NAME // E-MAIL FAX � .V 3 A IWC I N F iz/F u k LI j L L) �131 AJ C� I Com'.0 STREET ADDRESS CITY,STATE,ZIP PHONE 2_2 D161-7- 2. T O c e" 1 A-7-E> q/ 45- `-} ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: Commercial URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK /`�}%�j _ ,�J I l I r W E Z•t)f �-�MT V r- 2 171 � 1 ' � r TOTALVALUATION: /�'q�l ��l RECEIVED BY: ig 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 andverify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building const orize repres ino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: I Z5 Z SUPPL TAL TION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER ❑ EXPRESS U WU 5 ❑ STANDARD ❑ LARGE a ❑ MAJOR MEPMiscApp_2011.doc revised 03/16/11