12070144CITY OF CUPERTINO 13UILDING PERMIT
BUILDINGADDRF-SS: 10150CARNIENRD CONT'RACT'OR: TBS CONSTRUCTION INC PERMIT -NO: 12070144
OW'NEWS NAME: JOIiN S• CONNIE KAJING 3283 DE LA CRIT''/- RLVD STE A DA'Z'E ISSUED: 07/182012
OWNER'S I'DONE: 4084317185 SANTA CLARA. CA 95054 P1 [ONE NO: (408) 824-8x88
❑ _ LICENSED CONFRACI'OR'S/yDEC7LA/�RA7TION
License Clas�sfl�S Lie. q 041- /a 7 U ` 0
Contractor I Y )C-®'��'Sa 6UnG 110N rINCIte 7 - 02-17
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Dhi,sion 3 of the [business & Professions
Code and that inn license is in full force and effect.
hereby affirm under penalty of perjury oar 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
perfomtance 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 Ute work for which this
permit is issued.
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
Upon the above mentioned propeny for inspection purposes. (We) agree to save
indemnify and keep harmless the City ol•Cuperino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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.
Signatur `-'E Date 7-N-1
z
❑ OWNER -BUILDER DEICLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 Ibr sale (Sce.7044,
Business B Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
hereby affirm under penalty of perjury one of the following three
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.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation Imes of California. If, alter staking this cenificatc of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERT'IFICVI'ION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city mal county ordinances and state Imes 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 liabilitics,judgntents,
costs, and expenses which may accrue against said City in consequence of the
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.
Date
BUILDING PERMIT INFO: BLDG C ELECT I- PLUMB C
01ECH r RESIDEN'r1AL r COMMERCIAL I—
JOB DESCRIPTION: INSTALL NEW GAS LINE POR NEW GAS STOVETOP
Sq. Ft Roar Area: 1 Valuation: $2200
APN Number: 35709082.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: _ Dates
RF. ROOFS:
All courts shall be inspected prior to mty roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection. , A
Signature of Applicant: 14[ t.aM�er��"'��•` Date
�v
ALL ROOF COVERINGSTO BI's CLASS "A" OR BF" -1"I -ER
IIA"/-ARDOIIS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California Ileidth S Safety Code, Sections 255115, 25533, and 25534. I will mainbtin
coal Ill in are with the Cupertino Dl unicipal Code, Chapter 9.12 and the Ilealth S
Safety Code. Section 25532(x) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the [fay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
lealth S Safety Code. Sections 25505, 25533, and 25534.
Ow' er oraunt Irized Gent:
Date:_� i
CONSTRUCnON LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the perfomtance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Leader's Name
Lender's
ARCIIIT-ECI"S DI,CLARAT'ION
I understand my plans shall be used as public records.
Licensed
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE/ EQUIP TYPE
ADDRESS:
10150 carmen rd.
QTY
DATE: 07/18/2012
REVIEWED BY: bobs.
Flee. Permit Fee:
APN:
1PGASRES
BP#:
'VALUATION: $2,200
*PERMITTYPE:
Plumbing Permit
PLAN CIiECK TYPE: Alteration / Addition / Repair
PRIMARYSFD Or Duplex
USE:
Supp): hup Fee
PENTAMATION 1RPGA
I PERMITTI'PE:
YORK
install new
gas line for new gas stove top.
SCOPE
PME Permit Fee:
$45.00
APPLIANCE/ EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Flee. Permit Fee:
Piping, Gas <=4 Outlets
1PGASRES
Other Elce Insp.
1
#
$67
Permit Fee:
Supp): hup Fee
PME Unit Fee:
$67.00
PME Permit Fee:
$45.00
Construction Tial-:
Administrative Fee: InD,tIIN
$42.00
Work Without Permit? O Yes Q No
$0.00
TOTALS:
Travel Documentation Fee: ITR.UIDOC
$67.00
St, OnL MOl1On Fee: IBSE1SdlICR
NOTE: This estimate does not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sanita0• Sea,er District, School
District. etc.): These feev are based on the relintinar) information available and are onh, nn estimate Contact the De t or mldn7 in a.
FEE ITEMS (Fee Resohi ion 11-053 F_lL 7/1/11)
Mech. Plan Check
Plumb. Plan Check 0.0 1 hrs $0.00
Fl,,. Plan Check
Mech. Permit Fee:
Plumb. Permit Fee: IPPERMIT
Flee. Permit Fee:
Outer Much. Insp.
Other Plumb Insp.hrs $45.00
0.0
Other Elce Insp.
Pleeh. hup. Fee:
Plumb. htsp. Fitt:
Flee. Insp. Fee:
NOTE: This estimate does not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sanita0• Sea,er District, School
District. etc.): These feev are based on the relintinar) information available and are onh, nn estimate Contact the De t or mldn7 in a.
FEE ITEMS (Fee Resohi ion 11-053 F_lL 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check l-ee:
Sappl. PC Fee
PME Plan Check:
$0.00
Permit Fee:
Supp): hup Fee
PME Unit Fee:
$67.00
PME Permit Fee:
$45.00
Construction Tial-:
Administrative Fee: InD,tIIN
$42.00
Work Without Permit? O Yes Q No
$0.00
Ailwinced Planning Fees:
Travel Documentation Fee: ITR.UIDOC
$45.00
St, OnL MOl1On Fee: IBSE1SdlICR
$0.50
Select an Administrative Item
U lde SI(IS COn11111SSion Fee: IBCBSC
$1.00
SUBTOTALS:
$200.50
$0.00
TOTAL FEE:
$200.50
Revised: 0 7/0112 01 2
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 950143255
(408) 777-3228 - FAX (408) 777-3333 - buildinar7c auoertino.ora
'K IPLu'. TING 1 IVFrYaVifar FlPT;, - Tr Ar I I!1.lgf t ,U ny;e
MEP
M
EP -
M ISC
PROIECTADDRe35 c,
2d �
6 L�rL✓s"---rte`^
OWNER NAME C
p
51 71 rV S
E-MAIL
vw'. I E/
U C
STREET ADDRESS/0150 C
'
CIN. STAT)ZIP a
C,4- I fI2
FAX
WV1 1 W
�J (
CONTACT NAME
PH r/- 1 (Y y
E-MAIL
x a LA,
c(U Y)67
EET
STRADOAESSl eCTiY.AAS
Ci
FAX
ElOWTtElt 13OwNER-BUP.DER EIOWNER AGENT
(TATE
�CONTUCTOR 00N CTORAGFM ❑ Ask=Cr ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
g
CD 1CTORN
IV
L"V }IUf1ER LICENSE TYPE
BUS. LIC4
l W4-01/�
t)f
COMPANY NAME\ /
Q12NCC"I Ol/t
E -MAD.
GU N� %Gkl )Uh
FAX
J
STREET ADDRESS /
T $U I
CY,STAT
I PHONE
h
R
z J
.5 , Q.q I
ARCHTECTUENGINEM NAME
LICc1'SE NUMBER
BUS. LIC Y
COMPANY NAM.. '
E-MAIL
FAX
.S READDRESS
Com, STATE. ZIP
I P90NE
USE OF 91 s m DUPLE% ❑ MULTI-FAMR.Y
PROF -CT IN W❑DL1ND ❑ YES PROJECT` IN ❑ YES
iS TIM9CDGA.N ❑ YES
BUMP'G: ❑CO.VLSffRC1AL
URBAN INTERFACE AREA ENO FLOOD LONE ®NO
I
I ELCHLSR HOMEI lZNO
DESCRUMON OF WORK
-
W CO
TOTAL VALUATION: a SOD Ci c�
I RECEIVED BY:
By my signature below, I c=r ry m Tach of the following:
Ian the proper,/ owner or authorized agent m act on the pro ery owner's bchal; I have read this
application and the information. I have provided is CO=CL I have read the Description of Work and vmry it is accurate. I agree m comply with all applicable local
ordinances and sate laws relating ylbuilding con •ctioo. uthorize representadva of Cupertino to enter the above-idenCd�Sctlpro e'.1—./ for inspection puR{ oses.
Signamte of Applicant/Agenc
Date; �<
SUPP E--%1=AL INFORMATION REQURED
OFFICE USE ONLY
ID•OVER-THE-COUNTER
.
❑ EXPRESS
r
V
>t
❑ STANDARD
U
❑ LXRCE
Z
S
❑ NUOR
d4FP,Wtsc4pp_2011.doc revised 06/21/11