12080244 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23600 VIA ESPLENDOR#F108 CONI'BACI'OR:JESSUP PLUMBING INC PERMITNO: 12080244
O))'NER'SNAME: ROMAN CATHOLIC BISHOPOE SAN JOSE, PO BOX 2038 DATE ISSUED:08232012
OWNER'S PHONE: 5103936587 SANLEANDRO,CA 94577 PI ZONENO:(510)357-0525
❑ LICISNSED CONI'RACI'OR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT r' PLUMB r
License Clercs 3V,59 1 Lie.#!_1
�� DIECIi r RESIDI3NTIAL ri COMMERCIAL r
Contractor lQ551f� Date e5 Y
I hereby affirm that I:un dicer>rJ under the pnwisions of Ch• ter') •1013 DESCRIPTION:ADD DIRTY ARN,TRAP,WALL BOX
(conunencing with Section 7000)of Division 3 of the Business S Professions
Code and that my license is in full force and effect. V
I hereby affirm trader penalty of perjury one of the following two declarations:
I have and will maintain it certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perfommnce of the work for which this permit is issued Sq.Ft FloorArca: Valuation:$800
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued AI'NNumber:34254016.00 Occupancy Tape:
Arr1.R:nNr asaru IccrlcLN
I eenify that I have read this application and state thin the above information is
correct.lagree to comply with all city and county ordimmces and state laws relining PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree no save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemniN and keep harmless the City of Cupertino against liabilities.judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting ol'rliis permit. Addi' n l the applic nt understands and will comply
with all non-point scoreeyyyy��� ulanions pe he Cupertino Municipal C de,Section Issued by:' Date: �Z
9.18.
Signauir
RE ROOFS:
❑ OWNER-BIIILDh:1t DEC AR,VrION All roofs shall be inspected prior no any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all nesv materials for
1 herehy affirm that I am exempt from the Contractor's License Las%for one of inspection.
the following Isvu reasons:
1,as owner of the properly,or my employees with wages as their sole compensation, Signature of Applicant: Dale:
will do the stork,and the structure is not intended or offered for sale(Sce.7044,
Business R Professions Code)
I,as owner of time property,am exclusively contracting with licensed contractors to ALI,ROOFCOVERINGS-1.0 BE CLASS"A"OR BE;ITER
consumer rhe project(Sce.7044,Business S Professions Code).
1 hereby affirm under penalty of perjury one of the fulluwing three IIA%ARDOUS MATERIA)S DISCLOSURE
declarations: 1 have rend the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self insure for Worker's California I lcalth S Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance s%ilh the Cupertino Municipal Code.Chapter 9.12 and the Health&
performance of the work for which this permit is issued Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work lonu
vhich this contaminants as defined by the Bay Area Air Quality Management sDistrict 1 will
gamin is issued. maintain compliance with the Cuperlino Municipal Code.Chapter).12 and the
p Ilealth.4 •v Code.Sections 25505.25533.and 25534.
1 certify that in the performance of die 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 Ownc ithorize gent:
Compensation lases of California. If•after making this certificate of exemption,I Date-
become subject to rhe Worker's Compensation provisions of the Labor Code.I rm
forthwith comply with such provisions or this permit shall be deemed revoked, CC. ;'1'RUCI'ION LENDING AGENIC)'
I hereby affirm that th is a construction lending agency for the performance of ssurk's
APPLICANT CERTI 11CATION lot %hich this permit is issued(See.3097,Civ C.)
I certify that I have read this application and some than the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless Lite City o(Cupertino against liabilities,judgments, ,\ItClll'I'ECI"S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regularims per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
i Zv �-0 2-q
GENERAL PERMIT APPLICATION
' COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TOP.RE AVENUE r CUPERTINO, C„95014-3255 ' c
CUPERTINO-�// (408) 717-3228 - FAX (408)T 7-3333 - buildinc(ycuoemno.ora
ff?L 'M3LNG ❑!,EC?-A-VC/.4'_ ❑=LECT2?C?i/ �(/ ❑W5CzLLe NcOuS/
FRC=ADDDRESSn � O eul.ltrl� I AFN154
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57 R=1 I STAT;Z2! FAX
CONTACT NAM: I "'ONE
MT =.ADDRESS I MI.STATE. IIP
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CONIMANY NAME' I E-MAT= FAX
SRtE.t ADDRESS I CITY.STATE.ZIP
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USE OF ❑S,D m DUT(J( ❑ MULtrA Y PROTECT N WI DLAND ❑ Y E I PROD BI ❑YEs I IS The BLDG AN ❑ YES
BL ING: ❑COMMERCW. URBAN 1N=ACEAREA ❑ NO FLOOD ZONE ❑NO E+C-Z9i HOME: ❑NO
DESC�PDON OF MAX
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TOTAL VALUAroN:
,RZCEI' BY:
By my signature below,I cerd:y to each o;the` am the prope y owner or ac;hcrized agent to act on the prauery ewor' MMf. Knave read;his
application and the information I have provic- s ct I n.. a=d the Desription of Work and vriy is is aunLzle. xgn:e rn comply with all anphcable local
ordinance and s,-e laws mladng to bull" onsntr ti _ • =ze:cpm=-La of Cupe-n-c:c^m:the abov�-id ^mn .ce.-/far irspec�oa pu:bcses.
Signante of Applicant/Agent Dam: 3 1/
SUPPLEN=,s.L.TNFO A"I:O REQTT=D OFFICE USE ONLY
y ❑ OVER-THE-COUNTER
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❑ STANDARD
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❑ NWOR
MEPMsc4pD_2011.doc revised 06/-71/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 23600 via esplendor DATE: 08/23/2012 REVIEWED BY: larrys
` APN: BP#: `VALUATION: $800
*PERMIT TYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION
USE: Commercial Building PERMIITTYPE: 1CPFI i
WORK add dirty arm trap, wall box
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixture or Trap 113PFIXTURE 1 # $10
TOTALS: $10.00
,Nech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Fled.Plan Check
,bhrch. Permit Fee: Plumb. Permit Fee: IPPF-RVlT I Flec.permit Fee:
Other Much.Insp, Other Plumb Insp. 0.0 hrs Lnm
Other Elec.harp.
,tlech. Insp.Fee: Plumb. last). Fee: Flee.Insp, Few:
NOTE: This wintute sloes not include jeer due to other Departments(i.e. Planning, Public II'orks, Fire,Sanitary Server District,School
District, etc.). These fees are based on the prelitninan•information available and are only an winmte. Contact the De t or addnV info.
FEE ITEMS (Fee Resolution 11-053 E(! 7/1/11) FEE QTY/FEE MISC ITEMS
PlCln CIrL'CIi I'ee'
Suppl. PC h ee
PMH Plan Check: $0.00
Permit Fee:
Suppt Insp Fee
PME Unit Fee: $10.00
PML' Permit Fee: $45.00
Construction Tm:
Administrative Fee: IADAIhv $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VD0C $45.00
Suong Motion Fee: IBSEISIVICO $0.50 Select an Administrative Item
131da Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $143.50 $0.00 TOTAL FEE: $143.50
Revised: 07/01/2012