12050086 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7414 TIPTOE LN CONTRACTOR:NATIONAL ROOTER PERMIT NO: 12050086
OWNER'S NAME: LORD ROY SJR AND LEANNA TRUSTEE 2911 MONROE ST DATE ISSUED:05/082012
OWNER'S PHONE: 4082552860 SANTA CA LARA,CA 95051 PHONE NO:(408)241-0887
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class. 6 Lic.B 76?,3 0 r r r
MECH RESIDENTIAL COMMERCIAL
Contractor Delos-9-/'Z-
hereby a irm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL 50 GALLON WATER HEATER
(commencing with Section 7000)of Division 3 of the 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 which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq,FI Floor Area: Valuation:$1780
Section 3700 of the Labor Code.for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:35932060.00 Occupancy Type:
I certify that I have read this application and stale that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city 10 enter PERMIT EXPIRES IF WORK I$ 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 by: ��/✓ 1714 Z, / Date:
Signature Dale-S 8� IL
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed_If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,1 agree to remove all new materials for
the fallowing two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will du the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,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 1 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 I leallh&
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 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
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,afer making this certificate ofexemption,I Own r authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,1 must � TP�r��_Dale: S-_/1
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.)
correct. I agree to comply with all city and county ordinances and stale 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 acerae against said City in consequence of the ARCHITECT'S DECLARATION
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 plans shall be used as public records.
9.18,
Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 M ' /sem
CUPER'TTIIINO (408)77 (a�
7-3228•FAX(408)777-3333• buildinacuoertino.orD /c
—'Ll / / EWPLUNMINQ El MEaUMCAL ELECTRICAL ❑IASCELIANEOUS
"IROIECTADIIREIS AFN R L:5 —/ , 3,1 _ O (�
OWNER Q ONE�� - 60 EMAIL
STREETADD"m CTEY,STATE,ZD'. FAX
CONTACT NAME Q PHONE E-MAR
STREET ADD QEY,STATE O FAX
❑OWNEIl 00 wm.m=m ❑ OWNERAGQIT $tawra ACTOR ❑CONTRACTOR AGENT ❑ ARCWECr ❑E24GO1FEH ❑ DEVELOPER ❑ TENANT
COM7tACTOA LICENSE - �l I1RUS. C
W E-MAD. FAX
STAFEC ADDRESS � S-� CITY,SPATE PFIONE
2 /-08bj
AHCHTCECOENGINEER NAME LICENSE NUMBER BUS LIC d
WMPANYNAMEE-MAIL FAX
STREET ADDRESS CITY,STATE,IIP PHONE
USE OF ❑SFDMDUWFR ❑ MULTFFAKiLY FROIELTW WDDLANO ❑ Y6 PROIELTIN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COWKEltaLL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME! ❑NO
DFSIXBRON OF WORK
l /
I
,TOTAL VALUATION: RECEIVED BY:
Hy my signature belavr,I certify to each of the fvllowinr. I sum the property awaa or anthoriud agent to as on the property o er's behalf. I have read this
applicatlou and the i�ormatlon I have is carrect j have read the Desorption of Work and verify it is acnsa I to comply Midi all applicable local
ordidarces and save Taws relatmg to g cooi{metioa I au ' a repr moves of Cuperdna to mta tb above Ld 'fled property for inspection pt4oses.
Sign-aft ofApplIcaodAgeoe ATG Dam;
Stn&tMYEENTAL INFORMATION REQUIRED USE ONLY
OVER-THE-COUNTER
o.
❑ CRESS
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❑ LARGE
6
❑ MAJOR
AEPMecApp_2011.doc revised 06121111
l CITY OF CUPERTINO
Y l FEE ESTIMATOR- BUILDING DIVISION
ADDRESS-,,$71-4 Tiptoe Ln DATE: 05/08/2012 TREVIEWED BY: Sylvia
APN: BP#: 'VALUATION: 1$1,780
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration ( Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK INSTALL 50 GALLON WATER HEATER
SCOPE
,tle,;h. Plr,n C'h.rek Plumb.Plah Check 0.0 hrs $0.00 Elec. Man Che
11lech. Peru,it Fee: Plumb. Permit Fee: IPPERMIT li/rc. Permit l4•,:
Oder I fv,h. Lap. Other Plumb Insp. 0.0 hrs $44.00 Oilier E/cr. hr.,p.
111aeh. 1n.,p. Foe: P/umb. Lep. Fee: Elco. bull. Fee.
NOTE. This estimate does not include fees due to other Departments(le.Planning,Public Works, Fire,Sanitary Sewer District,School
District,eta). These ees are based on the prefimina information available and are only an estimate Contact the De t or addn 7 info.
FEE ITEMS (Fce Recohaion 11-053 F!! 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $26.00 /PRIPHEATR I Water Heater
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee.0 Reg. Q OT 0,0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $44.00
Conavrucfiun Tu.v:
Administrative Fee: ]ADMIN $41.00 O
Work Without Permit? O Yes Q No $0.00 G
Advanced Planning Fee. -Residential$0.00 Select aNon G
Travel Documentation Fee: ITRA VDOC $44.00
Building or Structure
Stronp Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $130.50 $26.00 TOTAL FEE: $156.50
Revised: 04/01/2012
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp:, Rng: Sub: Elk: Lot :
APN . . . . . . . . : 35932060 .00
DATE ISSUED. . . . . . . : 05/08/2012
RECEIPT #. . . . . . . . . : BS000016754
REFERENCE ID # . . . : 12050086
SITE ADDRESS . . . . . : 7414 TIPTOE LN
,SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : LORD ROY S JR AND LEANNA TRUST
ADDRESS . . . . . . . . . . : 7414 TIPTOE LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : NATIONAL ROOTER
CONTRACTOR . . . . . . . : RONALD J. PEREIRA LIC # 25124
COMPANY . . . . . . . . . . : NATIONAL ROOTER
ADDRESS . . . . . . . . . . : 2911 MONROE ST
CITY/STATE/ZIP . . . : SANTA CALARA, CA 95051
TELEPHONE (408) 241-0887
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 1,780.00 1.00 0 .00 1. 00 0 .00
1BSEISMICR VALUATION 1, 780.00 0.50 0 . 00 0 .50 0 .00
IBUSLIC FLAT RATE 1.00 119.00 0 . 00 119 . 00 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 275.50 0. 00 275.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 275. 50 #4725
---------------
TOTAL RECEIPT 275. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---- -- -- ---------------------------- -------- ----------------------------
518 WATER HEATER