12080133 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10768 ALDER BROOKLN ICONIRACI'OR:ONE DAY COMPLETE PERMITNO: 12080133
!I REPIPE
OWNER'S NAMIi: LEDWON STANLEY 1 I?I'AL 1658N 14111 ST' DATE ISSUEU:OS/I3R012
OWNER'S PRONE: 4086233376 I SAN.JOSE.CA 95112 PHONE NO:NOS)903-8)&
❑ LICIiN'SIit7 CON1'K,t CI'UIt'S IlEC1.ARAT'IC/V
Agar /� q BUILDING PERMIT INFO: BLDG r ELECT r- PLUMB r
License Class ( Lie.N
r r
Commctor Date % i11EC11 RESIDENTIAL COMMERCIAL r
_ //��.r�_ /� e_'_- �
�— r JOB DESCRIPT ION:WATER AND GAS REPIPE,REMOVE AND REPLCE WATER
(con] a inn that I do licensed under the (if ile Buof Chapter) IIEATER IN SAME LOCATION:NIOVE LAUNDRY FROM GARAGE
(commc cing ww nth Section 701111)of Ilivision 3 of the ISwiness.1 Professions
Code and th illy n'license is in full force and effect. TO INSIDE RESIDENCE.
herehy affirm under penalty of perjury one of the following nvo 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
perfrmmnce 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 perl'orniance of dm work for which this Sq.Ft Flour Area: I\Initiation:$9735
permit is issued pI
APPLICANT CERTIFICATION AISNNumber:36920043.00 I Occupancy Type:
I cenity that I have read this application and state that the above information is
correct, agree to comply with all city and county ordinances mid state laws relating
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes. (We)agree to Save PERMIT EMPIRES IF WORK IS NOT STARTED
indemnity and keep harmless the City of Cupertino against liabilities,judgments.
costs,and espenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply ►SO DAYS FROM LAST CALLED INSPECTION,
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Q `` /' ll
Signature Daic
Issued by: SEAN Nf7TG/f Date: J3 fa-
�f _
❑ OAYNER-BUILDER DECLARATION
RE-HOOFS:
I herehV affrn,Qillt 1:inn etcuipt front the Contractor',License Lan for one of All roofs shall be inspected prior to any roofing material beiig installed.Ira roof is
the follow iug two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the properly,or my employees wvi16 wages its their sole conipensoli0r, inspection.
will do the work,and the structure is not intended or ollcred for sale(Sec7044,
Business 3 Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,1usiness M Professions Code). ALL ROOF COVERINGS TO[IF,CLASS"A"OR BE,17ER
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 HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided Ivor by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health d Safely Code,Sections 25505,25533,and 25533. I will maintain
I have and will maintain Worker's Compensation insurance,as provided for by compliance.iith the Cupertino Municipal Code.Chapter 9.12 and the health S
Section 3700 of the Labor Code,for the performance of the work far which this Safety Code.Section 25532(a)should I store or handle hazardous material.
permit is slued.
Additionally',should 1 use equipment ur devices which emit hazardous air
cuntaminnn Ls an defined by the[lay Area Air Quality Management District I will
I cenily that in the per(ortnance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in my manner so as to become subject to the Worker's Ilealth S Safely Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate ofesemption.I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owitier0ri ithoriz _I i-s
forthwith comply with such provisions or this permit shall be decnxd revoked. Daly: �-/ �C/J—'
ItPI1LICA\'1'CF11TIFICIT'I(IN CONSI'RUC-HON LENDING AGENCY
I certify that I have read this application mid state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
I correct.I agree to comply with all city mid county ordinances mid state laws relating for whieb this permit is issued(Sec.3097,Civ C.)
to buildae construction,mud hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property Ivor inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address_
costs,and expenses which ntay 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 ARC111TECI"S DECLARATION
9.18. 1 understand illy plans shall be used as public records.
Signature Dam Licensed Professional
2 CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10768 Alderbrook Ln I DA'Z'E: 0 8/1 312 01 2 REVIEWED BY: Sean
\I APN: I BP#: 'VALUATION: 1$9,735 I
*PERMIT TYPE: Plumbing Permit I PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION 1RPFIX
USE: SFD Of Duplex PERINUT TYPE: A
WORT: I Water and qas reoioe: remove and replace water heater in same location: move laundry from garage to
SCOPE I inside residence.
APPLIANCE/EQUIP TYPE FEE 11) QTY UNITS BP FEES
Fixture Or Trap 1BPFIXTURE 1 # $10
Re-Pipe Interior 1PRREPIPE 1 # $13
Piping, Gas <=4 Outlets 1PGASRES 1 # $67
Water Heater 1PRWHEATR 1 # $27
TOTALS: $117.00
I
Mech.Plan Check I I Plumb. Plan Check 10.0 I hrs $0.00 1 Elea Plan Check
Afech.Permit Fee: ' I Plumb. Permit Fee: 1PPF.RAf1T I Elec.Permit ree-
1 Other,lfech.Imp. Other Plumb Insp. 0.0 hrs $45.00 Other Elce.lisp. u �_
Ilcch. Insp. rec: IILJJJ Phmd,. he,p. rec: Elm Insp Fee,
NOTE: This estimate doe%not include fees due to other Departments(i.e. Planning, Public Warks, Fire,Sanitary Sesser District,School
District,etc.). These fees ire baser/on the prelminary information available and are onh'an estimate. Contact the Dent for addn'I info.
FEE ITEMS (Fee Resolution 11-053 E(G 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee I 1
PME Unit Fee: $117.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: MDMIN $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITR.U'DOC $45.00
i
Strone Motion Fee: 1BSF.ISMICR $0.97 Select an Administrative Item
Bldg Sids Commission Fee: 1BCBSC $1.00 I
SUBTOTALS: $250.97 $0.00 TOTAL FEE: I $250.97
Revised: 07/01/2012
�5 v �l/"XV o-j— ., ✓ Z-�,-�U 13 3
GENERAL PERMIT APPLICATION UU E
COMMUNI (DEVELOPMENT DEPAR TMENT• BUILDING DNISION
10300 TORRE AVENUE • CUPERTINO, C"95014-3255 @� p
CUPERTIN+Oq� (408) r t-3228 • F.4X (408)T-77-3333 • buildincrcDwoerdno.ora M\®/�
LL}PLUNSING ❑,\'mCHANICAL ❑ELECT.ZC?t / ❑l,Ausc_-LL<NEGUS
?QOreeT.ADDRFSS/n MOW R1 rkP.6kr00 L `FN 4 �
2-C)OWNER NA1L MMi S T I e -U V 0 I/^ I Q 0 !/O n 7'j 7
S _FTADDRS4
/E/I ?/R �?/rG�rAk-00�— L/16I ^ iio r l �n� 0A FAX
CONTACT NAM - PRONE E•MP�
)nC� i1nP v.rSO_2�^j I ( �2_Co0/�?n/.�qS/(�� //� c� 1 l ,CPti AX
S�'dE-f ADDRESS/ [1 �, I �n Ln O N- ! W � �I / - F
❑OWNER ❑ O0W 'BBUUDDERR ❑ OWNU AGENT 4�CTOR ❑CDN, CrORA'NT ❑ ARC C ❑ENGINEER ❑ DEVELOPER ❑ 7-NANr
CONTRACTOR NAIM2— L'Cc^1SE NLM3ER'q'q 5(0q 2 I LICENSE TYPE d BUS.LIC a
COMPANY NANS n g i V o E-M I FAX
STRcTi ADORES '/�9 Al I T LI St 4 =1 .•57A1I 7�*,� PAONE
��/„ . , ns � Cog �l/ 7� u,M(�? lao3 OSZ>
AaC;r,s;ra,G ems- NAME — I LICENSE NIASEZ I Bus.uC n
CON,eANY NAME I EMAIL FAX _
ISTREET ADDRESS CITY,STATE,ZIP PHONE
BE OF SMD DUPLE( ❑ MULTI-FAMILY PROTECT IN WBDLAND ❑ YES PROTECT IN ❑ YES SitD:BLDG AN ❑ YFS
BU Owc: tjco' RC I URBAN INTERFACE AREA ❑ NO I FLOOD ZONE ❑No I EICHLEi HOME. XNO
WD CRIMON OF WORK I --
o((()C\n r 0 _�vri � � rJ Ce.S I �vu, E n I eTDn�- I L�t1 L'e'Vt&C /m
1 �vUglr_ T f Ohl Ci a., a n�, ,01— '� 1 A Y_M 1„ n 1.c:1 lti0l L.CC .COQ I�Y k-P/q t � - Y 01-.
Ln +(.( n��P/� �YOI�csll., oJ- JPuxA-I re Lour-e_, &ft4CQ L...,, [Pnr
livl.4'2'IGf C_ 'Cron , Crti l/ o�ci.r� t c� IIa ,���rL{ rnPr.
1,1 �9�e__ 1A
S I �J J ^/1
TOTAL VALUATION: 973 I RECEIVED BY:
Ay my signature below,I cerd.y to each of dte`ollowing: I am the p npc.,j owner cr amhoriud agca:a azt on the nnpery owce-.'s behalf 1 have read;hs
application aid the infarmadon I have provided is cot CL I have rt, d the Descrindon of Work and verify it is accvzte. I agree a comply with all applicable local
erdinamces and state laws rtlating m ng consnvcdon. 1 authoru rpresctaCVes of Cuneracc:c ene::S<(ab�ove-ideati5edp)mpa7P'Yor inspection purposes.
Signature of Applica z/Agenc� -%� _/I// Date: e /3 " /
/ SrUPiPL_E�IENT'AI'INTF�IZIv1AI l�N R.EQTJIILED �A OFFICE USE ONLY
y I W OVER-THE.COUXTER
Y
• I ❑ EXPRESS
U I+
=� I ❑ STANDARD
U
_a ❑ LAAGE
❑ MAJOR
:UIEP,Yfuc.4pp_1011.doc revised 06121171