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12040039 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22424 MCCLELLAN RD CONTRACTOR:' PERMIT NO: 12040039 OWNER'SNAMF-: JEFFREY WIDMAN ��.(. DATE ISSUED:04/06/2012 OWNER'S PHONE: 6509482831 l PHONE.NO: LICENSED CONTRACTOR'S DECLARATION r r r //�_ f/-�� 3 BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class ` ?" Lic.4 v poo 9 _4&2 EPl�' t alv �F-6 —1 MECH r RESIDENTIAL r COMMERCIAL r CommctorDa I hereby affirm that I am licensed under the provisions of Chapter JOB DESCRIPTION: REPLACE WATER HEATER LIKE FOR LIKE (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a cenificate 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.F1 Floor Area: Valuation:$1125 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35604023 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and slate 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 I80DAYS OFPERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the Igo 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 LL 9.18. Issued b 1�.f�/✓ 1i9'TlW Date: V-6-IL,91— Signature �A � _ by: Signature v` Date I� ❑ OWNER-BUILDER DECLARATION 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 remote all new materials for the following two reasons: inspection. I,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(Sce.7044, Signature of Applicant: Date: Business&Professions Code) 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 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. 1 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. Section 3700 of the Labor Code,for the performance of the work for which this 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 l will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 1 certify that in the performance of the work for which this permit is issued,)shall I leallh&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 ofCaftemio. If,after making this certificate of exemption,I Ower or au iz nl: J become subject to the Worker's Compensation provisions of the Labor Code,I must A Dater C. 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 work'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.) coffee[.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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this per .Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT, OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35604023 DATE ISSUED. . . . . . . : 04/06/2012 RECEIPT #. . . . . . . . . : SS000016478 REFERENCE ID # . . . : 12040039 SITE ADDRESS . . . . . : 22424 MCCLELLAN RD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : JEFFREY WIDMAN ADDRESS . . . . . . . . . . : P O BOX 1453 CITY/STATE/ZIP . . . : LOS ALTOS, CA 94023-1453 RECEIVED FROM . . . . : CHRISTOPHER N VANBR CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : 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, 125 .00 1. 00 0 . 00 1. 00 0 . 00. 1BSEISMICR VALUATION 1, 125.00 0. 50 0 .00 0 . 50 0.00 1PPERMITFE FLAT RATE 1.00 44 . 00 0 .00 44 .00 0.00 1PRWHEATR UNITS 1 .00 26. 00 0.00 26 .00 0. 00 1TRAVDOC FLAT RATE 1.00 44 . 00. 0.00 44 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 156. 50 0.00 156 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 275.50 VISA --------------- TOTAL RECEIPT 275.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO 191 . FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 22424 McClellan DATE: 04/06/2012 REVIEWED BY: APN: BP#: 'VALUATION $0 *.PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION PRWHEATR USE: PERMIT TYPE: WORK a lace gas water heater like for like SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater iPRWHEATR 1 # $26 TOTALS: $26.00 .ur,A /4nn Check Plumb. Plan Check 0.0 hrs $0.00 E/rc. P/....Chcrk alL•ch. P.-,inil Fee: Plumb. Permit Fee: IPPERMIT lilcr.. I.er.urir Fra: Ohbrr aicrh. ln.v'- Other Plumb Insp. 0.0 hrs $44.00 OtLrr Elcr./aep. lrz,p. /;cc: PleauL. hisp. Fee: lilcc. Liv'. F"e. NOTE: This estimate does not includejees due to other Departments(i.e Planning, Public Works, Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prefinddna information available and are only an estimate Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolulion II-053 Ell: 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check /•ce: ,Cupp!. PC Fc•e PME Plan Check: $0.00 Perneil Pitc•: Supp/, htcp Fee PME Unit Fee: $26.00 PME Permit Fee: $44.00 C'nnevruciiun Tfix. Administrative Fee: (ADMIN $41.00 Work Without Permit? O Yes 0 No $0.00 Advanced Maiming Fes: Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fec: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $155:00 $0.00 TOTAL FEE: $155.00 Revised: 04/01/2012 CS P-w+ � 12 --1 5 � GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 950143255 M I w CUPERTINO (408)777-3228•FAX(408)777-3333•building(opcuoettino.org (v_ PLUMBING MECHANICAL ELECTRICAL ❑NUCaLkNEOUS FROLECTADDRESS 22Tz1 / J'AR-S CII/e(/a,�I C �* �'yp' �p�-- OZ-3 Z �) DWNER NAME vi low\ 41id6lnco FRONEV Cd YT- E �/. r oe1 ,? /L Lg4a SIREETADDRESS r'`T CrIY. STATE,ZIPP FAX CONTACT NAME PHONE E-MAIL STREETADDRESS CITY.STATE. ZIP FAX ❑OwNFR ❑ OWNER-BUDDER . ❑ OWNER AGENT ❑ WNIRACO7R ❑WNTRACTOR AGENT ❑ ARGRTECt ❑ENGINEER ❑ DEVELOPER ❑ TOW4T CONTRACTOR NAME '/ /' GG^ 1P�lf SE NUMB� I�CFNSE T.�T EM UC O COMPANY NAME �J , E- IP ��P S/ ( FAx STREET ADOASS4� ` ['�/ /�1� t STATE.O S�Z� �O �OG� �J . ARCEDTECT/E NGINEER (NAME Il@lg NUMBER BUS.LIC F COMPANYNAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFDwDupLEx ❑ MULTLFAm.Y FRQmc:Tm WIDLAND ❑ YES PRONECTIN ❑ ISTHESLOGAN ❑❑Y/Et, RODDING: ❑WMMERcI& INTERFACE TERFACE AREA NO FLOOD ZONE NO EICHLERHOM yd'NO DESCRIPTION OF WORK TOTAL VALUATION: I 2 S:CXR RECENED BY: By my sip-"-below,I catify to each of the following. I am the property away ar authorized agent to act on the pmperty owner's bchalE I have read this application and the iaformadon I have provided is correct ban read the Description of Work and verify it is accurate. I agree to corn ply with all applicable local mdinmsa and stare laws relating to building=mtrnctiea I aotharize representatives of CLpatino to enter thelabbove-idde'au5ed pmpeM far hupecdon pu@oses. Signature ofAppll=r/Agena 'r Dam: SUPPLEMENTAL INFORMATION REQUOUD OFFICE USE ONLY r ❑ OVER-THE-COUNTER 6 ❑ E]WRESS Y U ❑ STANDARD u ❑ LARGE ❑ MAJOR MEPMtecApp_Z011.dbc revised 0621111