12040152 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7847 CREEKLINE DR CONTRACTOR:ANDY HORIUCI 11 PERMIT NO: 12040152
CONSTRUCTION
OWNER'S NADH:: CI-IEW KENNETH AND MARY L 8I7 LOS ALTOS AVE DATE ISSUED:04262012
OWNER'S PHONE: 4088027641 LOS ALTOS,CA 94022 PHONE NO:(650(948-2028
❑l LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
C—Ucense_Class -' - Lice q -7-k-3_X9 ( F_ F r
_ _ _� MECH RESIDENTIAL COMMERCIAL
_Contractor ---Date—. _.
112
-6 hereby affirm that I am licensed under the provisions of Chep erg JOB DESCRIPTION:ADD NEW UNDERGROUND GAS LINE FOR FUTURE
(commencing with Section 7000)of Division 3 of the Business&Professions OUTDOOR
Code and that my license is in full force and effect. KITCHEN
1 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
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued_ Sq.FI Floor Area: Valuation:$800
APPLICANTCERTIFICATION
1 certify that I haveread this application and state that the above information is APN Number:36217043.00 Occupancy Type:
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18. >�
SCignature `- Date Z( Z Issued by. Date:
❑ OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property.or my employees with wages as Weir sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the properly,am exclusively contracting with licensed contractors to Signature of Applicant Dale:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penally of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Section 3700 of the labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should 1 store or handle hazardous material.
permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of Cali font ia. If,after making this certificate of exemption,I - Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked.' er r.a h r eJ a e
Dater
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and stale that the above information is
correct.I agree to comply with all city and county ordinances and slate laws relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes,(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S ITECT'S DECLARATION
9.18.
t understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 7847 creekline DATE: 04/2612012 REVIEWED BY: bobs.
APN: BP#: -VALUATION: $800
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPGAS
USE: PERMIT TYPE:
WORK add new under ound gas line for future outdoor kitchen.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1PGASRES 1 # $65
TOTALS: $65.00
:t1,-,•h. Plan Chc k Plumb. Plan Check0.0 hrs $0.00 Elec. Phin
lie./,. 'e,wit Fee: Plumb. Permit Fee: IPPERM/1' Elev. Pe,n,i,htt:
Other Plumb Insp. 0.0 hrs $44.00 (m,, E/,c.Insp.
Phonb./asp. 1,v 17cc. 1,up 1-ee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina, information available and are only an estimate Contact the De t or addn7 in o.
FEE ITEMS (Fec Resolution 11-053 E(L 7/1/l f) FEE QTY/FEE MISC ITEMS
/Tarr Cheek Fre:
Suppl. 1'(:: Fee
PME Plan Check: $0.00
Permil Feu:
S'uppl, Imp Fre
PME Unit Fee: $65.00
PME Permit Fee: $44.00
('onsOvctinn Tal,:
Administrative Fee: MDA-iIN $41.00
Work Without Permit? Yes Q No $0.00
Aelcunccri Planning Feer:
Travel Documentation Fee: ITRA VDOC $44.00
Su Ona Motion Fee IRSFISMICR $0.50 Select an Administrative Item
131d-1 Sids Commission Fee: IRCBSC $1.00
SUBTOTALS: $195.50 $0.00 TOTAL FEE:j $195.50
Revised: 04/01/2012
GEN ERAL.PERMITAPPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 M I /�
CUPERTINO (408)777-3228•FAX(408)TT7-3333• buildina(o cuoeitno.ora /v_
PLUMBING MECHANICAL ELECTRICAL ❑MISCa ANEOUS
FROIECT ADDRESS 4 77- CR��k (---\ N E p R ,3J�- 1 -7- v
LY
OWNERNAME V ^rA 'A SJ
R. PHOH(q 00 602 ' 6 E-MAIL
ET
STREADDRESS ��-ti✓lf` V �Vt CIr1'. STALE,ZIP ` FAX
CONTACT NAME -TbT PHONE E-MAIL
SI'REHTADDRESS , CITY.STAM UP FAX
❑OWNER ❑ OWM-BUDDER - ❑ OWNER AGENT •❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHe= ❑EN@1gR ❑ DEVF Ek ❑ TENANT
CONTRACTOR NAME LICENSE NUNBER�(1/ C Q LICENSE TYPE BUS.LIC 0
COMPANY NAME MAD. rdd o a�S\5c- eL FAX
'1 � C' No2��AcN�
STREET ADDRESS Ci µ.ms]. LOS / -�1T O S �L CITY.STATE. L6
S AAT 0 S CIA
ARCHMMENGINE R.NAME` 1 Q LICENSE NUNIBER BUS.(OUC p
COMPANY NAME' ✓' E-MAIL. FAX
STREET ADDRESS MY.STATE,ZIP PHONE
USE OF ❑SFDmDUPIFX ❑ MUMFAMII.Y PROIECTINWILDLAND ❑ Y6 PROIERIN ❑YEB iS THE BLDG AN [I YES
BUDDING: ❑cowxEan.r URBAN BREtFACE AREA 13NO FLOOD ZONE' [1 NO F]QO.EIl HOMEI 0 N
DESCRIPTION OF WORK -7� �-T AN G U (J
0 C-A s L I N e -
Ac
TOTAL VALUATION: C)o I'-- RECEIVED BY:
By my Signature below,I certify to each of the following- I=the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the infarmsuou I have provided ucorrpcLd have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating m g m stmt'ori arae representatives of Cupertino m enter the abav 'dm fled peZ--
SUPPLEMENTAL
m for bapectien purposes.
Signatue of AppliraaNAgent_ Date: � C_
SUPPLEMENTAL INFORMATION REQIJIRED � OFFFICE USE ONLY
L'J-
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❑ EXPRESS
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❑ STANDARD
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❑ NAGE
❑ MAJOR
MHPMucApp_2011.doc revised 06121111