12080266 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22401 SANTA PAULA AVE CONTRACTOR:FALCONE PLUMBING& PERMIT NO: 12080266
ABATING INC
OWNER'S NAME: BI7RGEN CHRISTOPHER D AND KIN113ERLY M 1155 PEMBRIDGE DR DATE ISSUED:081272012
OWNER'S PHONE: 4084700477 SAN3OSE.C\ 95118 PHONE NO:1408)293-5676
❑ LICENSED CCONI'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG I✓ ELECT 1-, PLUMB IJ
License Class
INECII I- RESIDENTIAL 1-• COMMERCIAL r
Contractor/ Datc t.7 b
to r"hy�alfirm Ihal I am licensed under Ibe provisions of Chapter 9 30B DESCRIPTION;INSTALL TANKLESS WATER HE
AT RIGHT SIDE OF
(commencing with Section 7000)of Division 3 of the Business& Professions HOUSE.INSTALL NEW FURNACE IN BASEMENT
Code and that my license is in full force and effect.
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.Ft Floor Area: Valuation:$10000
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued.
.\I'1'hICAN1'CI:R'I'IPIC\'PION .0;N Number:35704007.00 Occupancy Type:
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 state 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 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. dditionally,the applicant understands and"ill comply -
with allnon-p t sour regulations
per the Cupertino Municipal Code,Section / 7
9.18. Issued by:�C�� ��f GH Date:
Signatu Dnte err/Z7/�L_
❑ OWNER-BUILDER DECLARATION RF,-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby,nllirm that 1 am exempt from the Contractor's License haw for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees%kith wages as their sole co ircrisalion,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of ApplicanC Date:
Business&Professions Code)
I,as owner of 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
hereby affirm under penalty of perjury one of the following three
declarations: DA7,ARDOUS MATE RIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I hake 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 Cade.Chapter 9.12 and the Health&
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)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 Ray Area Air Quality Management District 1 will
maintain pliance 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,l shall Health& f&za
ections 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,aper making this certificate of exenmpiion,I Own�o utear:
becomesubject to the Worker's Compensation provisions of the Labor Code,I must Dater
forthwith comply with such provisions or this permit shall be deemed revoked,
CONS'I'RIICI'ION LENDING.\GF,NCI'
APPI,ICANI'CF,R'TIFIC.VI'ION 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 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 permit.Additionally,the applicant understands and will comply ARCI I ITECT'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
GENERAL PERMIT APPLICATION E P
CONIMUNII'DEVELOPMENT DEPART MEN7• 5UILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 M w I s c
CUPERTfN (408)7 -3228 • FAX (408)T777-3333 • buildincrc cuoeaino.ora M.�O7� irr
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USE OF 'Dv Dt]PLE( ❑ MULTI-FANCY PROrECTW WRALWD ❑ YS PR=-m IN ❑ YES IS THE BtDG.V! ❑ YES
BUE.OWG: COMMERCIAL I URBAN WTERFACE AREA ❑ NO I FLOOD DANE ❑NO I EImE.F.A' HOME? XNO
DSCRIPRON OF WORK 1
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ties
TOTALVALUATMN: D I RECEIVED BY:
By my signature below,I ,:.ry to ch f rhe fo owing: I am the pmpe-y owner or auJ-,orized agent to act on the propery owner's behalf. I have read this
application and the information i b e p ' edortecL I have read the Description o:Work and verify it is accurate. I agree io comply with all applicable total
ordinances and sam laws relating bu' g ruction. I authorize mprnSCeawes of Cuner a:c c::mr rheybove-idd�cjn, d _pmpe.—./-r inspection pu;�oses.
$igaamre of Applicant/AgeaC Dave: ` 1/ _ 7 V
SUPPLEMENTAL rNFORNLAMON REQUU ETD OFFICE USE ONLY
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AePMuc4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 22401 Santa Paula Ave DATE: 08/27/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $10,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD Or Duplex PENTAMATION pRWHEATR
USE: PERMITTYPE: A
WORK Install tankless water heater at right side of house. Install new furnace in basement.
SCOPE
Mech. Plan Check 0.0 1 hrs $0.00 Plumb. Plan Check 1 0.0 hrs $0.00 .Elec.Plan Check
Mech. Permit Fee: IMPERMIT Plumb. Permit Fee: /PPERMIT Elac. Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp. 0.0 hrs 1$45.00 Other Clec. Insp.
rllech.h>,pt. Fee: Plumb. b1sp. Fee: Clec.Insp. Fee.•
NOTE: This evtinrrtte does not include jeev due to other Departments(i.e. Planning Public H'orks, Fire,Sanitary Sewer District,School
District, etc.). Thesefees are based on the prefintinan information available and are onh,an estimate Contact the Dettifor addn7 info,
FEE ITEMS (Fee Resolution 11-053 E1T 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl. PC Fee: e) Reg. O OTFO-0-1hrs $0.00 $27.00 IPRn'llEATR I Water Heater
PME Plan Check: $0.00 = # Mechanical
Permit Fee: $0.00 $133.00 1A-tFR=<I00 Furnace, Forced-Air
Suppl. Insp. Fee-.0 Reg. Q OT FO,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $90.00
Conswuction Ta.r:
Administrative Fee: 1,1DMIN $42.00 O
Work Without Permit? Yes Q No $0.00 0
Advanced Plannine Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRA VDOC $45.00 Building or Structure
A
Strong Motion Fee: IBSEISMICR $1.00 Select an Administrative Item
Bide Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $179.001 $160.001 TOTAL FEE: F$339.001
Revised: 07/01/2012