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12090160 CITY OF CUPERTINO BUILDING PERMIT RUILDING ADDRESS: 10142 CO1.BY AVE CON'1'RACI'OR:CIMA PLUMBING& PERMIT NO: 12090160 CONSTRUCTION OWNER'S NAME: SUSAN SHIN 586 N FIRSI-STSIT 111 DATE, ISSUED:09/19/2012 OWNER'S PHONE: 4082029334 SAN JOSE,CA 95112 PHONENO:(408)594-1161 ❑ /-LIC2ENSE[)CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I~ ELECT I- IJ PLUMB License Class C' 7 1�2 Lic.N 1 �jx cc�A, / p1EC11 r RESIDENTIAL r COMMERCIAL r Contactor C.\MO. 'EVD-Vn�44u, � _ (�"),:L / 1 Z hereby affirm that 1 am licensed under thelprro%inions of Chap !!!!!! •10B DESCRIPTION: INSTALLATION.OFFAS LING TO STOVE (commencing with Section 7000)of Division 3 of the Business S Professions 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. Sq.Ft Floor Area: Valuation:$350 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. APN Number:3 162803 1.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.l agree to comply with all city and county ordinances and state lass relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby outhorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify 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 of this permit. A dilt.onally,the applicant understands and will comply _ with all non-points a ulations per the Cupertino Municipal Code,Section Issued by: ��/v rJTIi�J Date: •/� •� 9.18. Signal e Dateq� 17 �� RF--ROOFS: ❑ OWNER-BUILDER 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 nese materials for 1 herebyaffirm that 1 am exempt from the Contractor's License Lass for one of inspection. the follow'I ng two reasons: 1,as owner of proper,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 ds Professions Code) I,as owner of properly,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business d Professions Code). hereby affirm under penally of perjury one of the following three HAZARDOUS 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 Ilealth 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 with the Cupertino Municipal Code.Chapter 9.12 and the Health S performance of the work for which this permit is issued. Safety Code,Section 25532(x)should 1 store or handle harnrdous 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 Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth S Safety C rf .Sections 25505.25533.and 25534. 1 certify that in the performance of the work forwhich this permit is issued,I shall /� not employ any person in any manner so a5 to become subject to the W'orker's Ow'ne a ze agent: Compensation laws of California, If,after making this certificate of exemption,I Dale:�r C/ become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deerned 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 1 have read this application and slate dial 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 the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the graining 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 GENERAL PERMIT APPLICATION TNI E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 A I A CUPERTINO (408)777-3228 nn 228• FAX(408)777-3333 • buildinacuoeninD.orD '\e/I v\ PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRE51 I • \ -Me- • I I "0(\/J/ �l„), ( OWNER N ` PHONE3 E-MAIL sTREET ADD =ss \ v cm. sT.cr�zsP n CQ FAx VJ �t I CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX OWNF]t ❑ OUPNER-BADDER ❑ OWNERAGD47 NTRACTOR ❑CONTRACTOR AGIDIT ❑ ARCHITECT ❑FNGNEER ❑ DEVELOPER ❑ tANT CONTRACT ORN E � LIC � ER � LICENSE TYPE BUS.CIS p ` COMPANY \ I EIMAfL .r VC T1 FAX C1 �7 'y ITY.STti ZIP GSkjZ I4(JS '` --iM ARCH KTTERJ 1FNGDdEFR NAME'MI ,s / LICENSE NUMBER BUS.LIC 0 COMPANY NAME' E-MAIL FAX STREET ADDRESS I CITY.STATE.ZIP I PHONE USE OF %FD DUPLEX ❑ MULTI-FAMMY PROJECT N WD.DLAND ❑ YES I PROJECT IN ❑YES I ISTHSBIDGAN ❑ YES BUILDING: 000M RCW. IMANNTEIFACEAREA NO FLOOD ZONE NO EICHL HoM O DESCRIPTION OF WORK Q` X TOTAL VALUATION: 3 RECEIVED BY By my signature below,I certify to each of the following: I the property owner or authorized agent to act on the pmperry owner's behalf. I have read this application and the information I have provided is. s come av ud rhe Description of Work and verify it is accurate. I agree o comply with all applicable local ordinances and sate laws relating In buildingcons o t ries repmsenatives of Cupenino to enter the above-id p ery for inspection puiposes. Signature of AppliwnJAgca[: Dale: LA /L SUPPLEMENT ORMATION REQUIRED OFFICE USE ONLY t ER-THE-COUNTER PRESS Y U m ❑ STANDARD U < ❑ LARGE ❑ MAJOR MEP:YfucApp_2011.doc revised 06/21111 - CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10142 Colby Ave DATE: 09/19/2012 REVIEWED BY: Sean \ APN: BP#: 'VALUATION: $350 *PERMIT TYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration /Addition / Repair PENTAMTYPE: PEATION RMIT TYPE: PRIMARY USE: SFD Or Duplex 1RPGAS WORT: Installation of gas line to stove. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $67 TOTALS: $67.00 Xlech. flan Check Plumb. Plan Check 0.0 hrs $0.00 Flea Plan Check Meth. Permit Fee: Plumb. Permit Fee: IPPERAIIT face. Permit Fee: Orlter,tlech,Insp. Other Plumbinsp. 0.0 hrs $45.00 Other Elce.insp. Ale.ch.Insp. Fee: Plumb. hisp. Fee: Elec.Insp.rec. (VOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Warks, Fire,Sanitary Sewer District,School District,etc.). These feev are baser/on the preliminai3 information available and are on/v an estinmte. Contact the De t or addn'I in a. FEE ITEMS (Fee Resolution 11-053 E0: 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fec PME Plan Check: $0.00 Permit Fee: Suppl. hisp Fee PME Unit Fee: $67.00 PME Permit Fee: $45.00 Consnvtction Tac: Administrative Fee: LIDAHN $42.00 Work Without Permit? O Yes Q No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRA VDOC $45.00 A Strong Motion Fee: IBSE/SMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $200.50 $0.00 TOTAL FEE: $200.50 Revised: 07/01/2012