12090026 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10350 MANN DR CON TRACTOR:DEMPSTER PLUMBING PERMITNO: 12090026
OWNER'S NAME: MESSMER ELIZABETH E 1639 POMONA AVE DATE ISSUED:09/052012
OWNER'S PRONE: 4082533750 SANJOSE:,CA 95110 PHONE NO:(408)295-3911
Cal LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLU01B
License Class L—�i Lic.d g g l- �O[1 r r_ r
(]�_f p MECII RESIDENTIAL COMMERCIAL
WIL 4M O f/'lYCi' 4J Date-5L4117,_
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-PIPE INTERIOR AND NEW WATER SERVICE
(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:
1 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.
Sq.Pt FloorArea: ValualionT$650
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'N Number:32615005.00 LO�eCopan"Fy
APPLICANTCERTIFICATION
I certify that I have read this application and state that the above hubmnation is
correct. I agree to comply with all city and county ordinances and stale laws relating PERMIT EXPIRES IF W tit VOT STARTED
to building construction,and hereby authorize representatives of this city to enter � �w�
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN DAYS OF1.PF2It HISSUANCE OR
indemnify and keep harmless the City of Cupenino against liabilities,judgments, t�
costs,and expenses which may accrue against said City in consequence of the 180 DA OM 'S. 'CA LED INSPECTION•
granting of this permit. Additionally,the applicant understands and will comply
g 8 P X PP P T
with all non-point source regulations per the Cupertino Municipal Code,Section Issue) b)': Dale:
9.18. �y
Signature Dae t;m
�7
RF-ROOFS:
❑ O\\•NER-IIIIILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.if a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three IIAZARDOUS MATERIALS DISCLOSURE
declarations: I have read 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 Health&Safety Code.Sections 25505.25533.and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with 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 I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the[lay Area Air Quality Management District 1 will
ermit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
P
I certify that in the performance of the work for which this permit is issued,Ishall Health&Safety Code,Sections 25505,25533,and 25534./7
not employ any person in any manner so as to become subject to the Worker's Owe n th rFzoA a
Compensation laws of California. If,after making this certificate of exemption,1 hate: 7 �Z
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and slate 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 the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCIIITEC`I"S DECLARATION
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 regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
Septic Tank — - - _- - — — - - - -- - - --
Sheet Metal
GENERAL PERMIT APPLICATION E
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 T ORRE?VENUE • CUPERTINO, CA 95014-3255 M ® I C
CUPERTINOO� (408) 7Tr-322,8 •7 FAX(408)7777-3333- buildinGOCUoerino.ora \F]��
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13y my sig:e_-e below,I c^.y;o each Of me follms^_g: I a—:he propc.-y owner or=::proud agent to ac:on the nrope;y owner's behalf 1 have road this
anplica on z^.d cSe iam= I have nrov d is Cor_c: I d"' Description of Work and verify k is amaze. I aye:m comply wiLh all applicable local
or+unans cand sa¢laths mlz:ir. bull bucans Co. on+^:e^rescadves ai Cuper..=c_^_L:LSe av--jdcu$e3prcpef for inspe<don pu:peses.
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SUPPLENENTAS.W:ORMATiON R-EQTJUED OFFICE USE ONLY
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M6PMLsc.4pp_2011.doc revised 06/21111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
:21 ADDRESS: 10350 Mann Dr. DATE: 09/0512012 REVIENVED BY: gs
APN: BP#: 'VALUATION: 1$6,500 '
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1RPRP
USE: PERMIT TYPE:
11'ORK Re- i e interior and new water service
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Re-Pipe Interior 1PRREPIPE 1 # $13
Water Service 1BFwsvCs 1 # $23
TOTALS: $36.00
,Ltech. flan Check Plumb. Plan Check 0.0 Ins $0.00 Flec. flan Cherk
blech. Permit Fee: Plumb. Permit Fee: /PPERAHT Elec.Permit Fee:
Oiher,Rech. Insp. Other Plumb Insp. 0.0 hrs $45.00 01her'Elec.Insp.
,Hoch.Iasp. roc: Plumb. brat). Fee: Elec.hap. Fee:
A'OTE: This estimate does not include jeer clue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Seiner District,School
District,etc. . Thesefees are based on the prelitninan information available and are only an estimate. Contact the De t or athin'I info.
FEE ITEMS (Fee Revolution //-053 F_(! 7/1/Ill FEE QTY/FEE MISC ITEMS
Plun Check Tee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Snppl. /its/)Fee
PME Unit Fee: $36.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: 1ADMIN $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fces:
Travel Documentation Fee: ITRdPDOC $45.00
Strone Motion Fee: IBSEISMICR $0.65 Select an Administrative Item
I31de Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $169.65 $0.001 TOTAL FEE: $169.65
Revised: 07101/2012