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12020011
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20333 CLIFDEN WAY CONTRACTOR:ROTH MECHANICAL PERMIT NO: 12020011 OWNER'S NAME: WILLIAM THROM 1883 POTRERO DR DATE ISSUED:02103/20t2 OWNER'S PHONE: 4082551849 SAN JOSE,CA 95124 PHONE NO:(408)858-2802 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTfON: RESIDENTIAL COMMERCIAL License Class I" Lic.# W-4 REPLACE WATER HEATER AT SAME LOCATION Contractor �p � �le�Lr 1- �—Date c,7-1 03`( I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of tile 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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$1200 I have and will maintain Worker's Compens<ntion Insurance,as provided for by Section 3700 of the Labor Code,for die performance of the work for which this APN Number:36937004.00 Occupancy Type: permit is issued. .APPLICANT CERTIFICATION I certit},that I have read this application and state that the above infortnation is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating 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 inspection purposes. (We)agree to save 1.80 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City inconsequence of the Issued b, ��— Date: r granting of this permit. Acl tionally,the applicant understands and will comply with all non-point so "u at'.IS per the Cuperti unicipal Code,Section 9.18. RE-ROOFS: Sig ature Date rZ All roofs shall be inspected prior to any rooting material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirin that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the 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.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATER[ALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of tl►e California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided fix by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by tl►e Health&Safety Code,Sections 2550 ,25533,and 25534. Section 3700 of the Labor Code,for die performance of the work for which this Owner or authorized agent Date: permit is issued. I certify that in tie performance of the work tor'which this pernlit is issued,I shall not employ any person in any manner so is to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If,atter making tris certificate of exemption,I beccxne subject to the Workers Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction leading agency for ttie performance of torthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certity 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 upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be 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: 2-0-67 )b 6-`,�vFok=-AA PERMIT# PHONE# OWNER'S NAME: Nle `�.i i} u '► �'Fl�r' � 2 GENERAL CONTRACTOR: BUSINESS LICENSE# 3 Z-4 b"r ADDRESS: 1 �3 n c� CITY/ZIPCODE: oS� CA, S L *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 SUBCONTRAC / AVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Date Signature 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 CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: sylviaM 6 ITEMS OF 6 COPY # Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . 36937004 .00 DATE ISSUED. . . . . . . 02/03/2012 RECEIPT #. . . . . . . . Bs000015913 REFERENCE ID # . . . 12020011 SITE ADDRESS . . . . . 20333 CLIFDEN WAY SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : WILLIAM THROM ADDRESS . . . . . . . . . . : 20333 CLIFDEN WAY CITY/STATE//ZIP . . . CUPERTINO CA, 95014-4460 RECEIVED FROM . . . . LEONARD ROTH CONTRACTOR . . . . . . . LEONARD ROTH LIC # 32188 COMPANY . . . . . . . . . . ROTH MECHANICAL ADDRESS . . . . . . . . . . 1883 POTRERO DR CITY/STATE/ZIP . . . SAN JOSE, CA 95124 TELEPHONE . . . . . . . . (408) 858-2802 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ------------- ---------- ---------- ------- -- --------- -_---_ ---------- - -------- 1 .00 41. 00 0 .00 41.00 0 . 00 1ADMIN HOURS 0 . 00 1 .00 0 .00 1. 1BCBSC VALUATION 1, 200 -00 00 0 .00 1BSEISMICR VALUATION 1,200 -00 0 . 50 0 .00 0 .50 1 .00 44 .00 0 .00 44 .00 0 . 00 JPPERMITFE FLAT RATE 1 .00 26 . 00 0 .00 26 .00 0 .00 1PRWHEATR UNITS 1 .00 4400 0 .00 44 .00 0 .00 . 1TRAVDOC FLAT RATE ---------- ---------- -- ------- TOTAL PERMIT : 156 .50 0 .00 156 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ---------------- --------------- CREDIT CARD 156 .50 visa TOTAL RECEIPT 156 .50 VOICE ID DESCRIPTION VOICE ID ---------------- DESCRIPTION--------- -------- ------------------ -------- ------------ 518 WATER HEATER CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 20333 clifden way DATE: 02/03/2012 REVIEWED BY: bobs. APN» BP#: 'VALUATION: $1,200 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY PENTAMATION PRWHEATR USE: SFD or Duplex PERMIT TYPE: WORK re lace water heater at same location. SCOPE APPLIANCE 1 EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $26 TOTALS: $26'00 Plumb.Plan Check 0.0 hrs $0.00 F- Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $44.00 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 the L!relininary information available and are o!!! an estimate. Contact the Dat-Lor addn'1 in o. FEE ITEMS. :3 ).1',;,, '1 4';-' f ?,�� FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $26.00 PME Permit Fee: $44.00 Administrative Fee: IADMIN $41.00 Work Without Permit? 0 Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 IaSEISMICR $0.50 Select an Administrative Item C011-11flisSiOra Fle: IBCBSC $1.00 SUBTOTALS: $156.501 E0 TOTAL FEE: $156.50 Revised: 1/19/2012 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC (408)777-3228 • FAX(408)777-3333• building cupertino.org_ CUPERT{NO I /-)U V(- PLUMBING ©.mrCfIANICAL ELECTRICAL ❑MISCELIANEOUS $ . -7 PROJECT ADDRESS 7-0`.��'`�,� /a ;f� � W APNc� (-f / C��-�- PHONE ^ZJS, i�- �� E-MAIL OWNER NAME CITY, STATE,ZIP ( FAX STREET ADDRESS. 1 3 =uN `J PHONE E-MAIL CONTACT NAME�' CITY,STATE, ZIP FAX STREET ADDRESS ❑OAR ❑ OWNER-BUILDER ❑ OWNER AG t CONTRACTOR ❑CONTRACrORAGE4T [3ARCHITECT 13 ENGINEER ❑ DEVFLOPER ❑TENANT LICENSE NUMBER LICENSE TYPE BUS.LIC CONTRACTOR NAME . 9 1 -- -0 2 E-MAIL FAX COMPANY NAME c'ZJ `DLA U 7 CITYSTATE,ZIP PHO N —ySY- 25�rL STREET ADDRESS (� ✓ 1 , —�• Ls'� S Z ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# E-MAIL FAX COMPANY NAME' CITY,STATE,ZIP PHONE STREET ADDRESS RO1ErTTN 0 YES IS THE BLDG AN YES USE OF SFD or DUPLEX ❑ MULTI-FAMII Y PROJECT INTERFACE AREA 13 O FLOOD ZONE [3NO EICHLER HOME? ❑O BUILDING: ❑COMMERCIAL DESCRIPTION OF WORK r� `,,, RECEIVED BY: TOTAL VALUATION: � L.4.C/ 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 ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to builauthorize representatives of Cupertino to enter the above-i entifie property for inspection putposes. Date: t7'Z—�0J��Z Signature of Applicant/Agent- SUPPLEMENTAL INFORMLAnON REQUIRED OFFICE USE ONLY ❑ OvER-THE-COUNTER yam. F ❑ EXPRESS Y W ❑ STANDARD U < ❑ LARGE a ❑ MAJOR MEPMIscApp_2011.doc revised 06121111