Loading...
12100156 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 10912LEAVESLEYPL CONt'RACI'4)R:'I"BD-TO131i DETERMINED PF.RMITNO: 12100156 OWNER'SNAME: GALLr EDWARD I AND KAREN L e m - DATE ISSUED: 10222012 OWNER'S PHONE:E: 4089960762 1'I IONF.N'O: ❑ LICENSED CON7RACrbR'SS DECLARATION BUILDING PERMIT INFO: BLDG r ELECT rI PLUMB 5— License License Class C 3 G Lie.N / MECFI (- RESIDENTIAL r COMMERCIAL 0— Contractor Contactor T 1/9Gq i"��ryDafe �c>^ZZ—� hereby affirm That I vat licensed under the provisions of Chapter 9 J 0 B DESCRIPTION: REMOVE AND REPLACE WATER IIEATER (commencing with Section 7000)of Division 3 ofthe Business&Professions Code and that my license is in full force and effect. Ihereby affirm under penalty of perjury one ofthe following two declarations: 1 have and will maintain a certificate of consent t0 self-insure for Worker's Compensation,as provided for by Section 3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft floor Arca: Valuation:$1200 Section 3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. APN Number:35615030.00 Occupancy'I)'Pc: Al'1'1.ICAN1'CICR'I'IFICA'1'ION 1 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 Imus relating to building construction,and hereby authorize representatives oflhis 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 Ci(yofCupertinoagainstliabilities.judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence ofthe 1 gl) DAY F OM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands mid will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issuer Irv: L Date: Signature Date e'—u-12— ❑ ON'NFR-BUILDER DECLARATION RL-ROOFS: All roofs shall be inspected prior to any rooting material beiig installed.If a roof is hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of'Appliront: Date: Business&Professions Code) I,as owner of the property,am exclusively contacting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF CO\'ERINGS"I'O 13E CLASS",\"OR 13E7"fliR herclis.afirm under penally of perjury one of the following three declarations: IL\%ARDOIIS MATFRL\LS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have 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 I Iealth&Safely Code,Sections 25505.25533.and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health& I 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 ofthe Labor Code,for the performance ofthe work for which this Additionally,should I use equipment or deviceswhich emir hazardous air permit is issued, contaminants as defined by the Bay Area Air QualityManagemcnt District I will maintain compliance 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,I shall Health&Safety Code.Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws ofCalifamia. If,after making this certificate ofexemption,1 0"aer urr 1 rrzgd eat: .Z become subject to the Worker's Compensation provisions ofthe Labor Code,I muss hate: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 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 stale laws relating Lender's Name to building construction,mid hereby authorize representatives of[his 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 Cupenino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCIIITECI"S DECLARATION granting oflhis permit.Additionally,the applicant understands and will comply 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 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOBADDRESS: JOCI 1 2 -C P PERMIT# OWNER'S NAME: e4ex L;4a14 PHONE# GENERAL CONTRACTOR: C'K S ZAV ,•41iq BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: *Our municipal code requireti all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL 13E SCHEDULED_ UNTIL THE GENERAL CONTRACTOR AND ALL SUBCON'1'ItA 'FORS iAVE OBTAINED A CITY OF CUPFRTINO BUSINESS LICENSE. J J 1 am not using any subcontractors: 7 2-1 Z Signatur Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum /Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting./Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet-Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10912 LEAVESLEY PL DATE: 10/ 2/2 01 2 REVIEWEI) BY: MENDEZ APN: BP#: VALUATION: 1$1,200 *PERMIT Tl'PE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PLN'/AI1IA I ION PRWHEATR USE: PERMIT TYPE: WORK REMOVE AND REPLACE WATER HEATER SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $27 TOTALS: $27.00 ,llech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 F.Iee. Plan Check Nfech, Permit Fee: Plumb. Permit Fee: IPPERMIT tree.Permit Fee: Other Meek Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Flee.Insp. ET ie&Insp. Fee: Plumb. brsp. Fee: Flee.hup.Fac: NOTE: This estimate does not include jeer Clue to other Departments(i.e. Planning, Public Narks, Fire,Sanitary Server District,School District,etc.). These' ees are based on the prefindnan information available and are onh,on estinate. Contact fire Det or adt/rn7 in a. FEE ITEMS (Fee Resolution 11-053 Elf 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Suppl. /nsp Fee PME Unit Fee: $27.00 PME Permit Fee: $45.00 Catswuction Tax: Administrative Fee: 1dDMIN $42.00 Work Without Permit? O Yes 0 No $0.00 Advancecl Plarming Fees: Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion'Fee: IBSFISA/ICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $160.501 $0.001 TOTAL FEE: $160.50 Revised: 10/01/2012 l ZI vvt �� GENERAL PERMIT APPLICATION M E 1 - C COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M isc CUPERTINO (408) 777-3228• FAX(408)777-3333• buildina(c)cuoerino.ora fPLUMIDLNG [:)),MCHANICAL ❑ELECTPJCAL ❑MIISCELL EDU5 PROJECT ADDRESS iO /�[`! ley,- / -3 OwNc^nN rd 6; ,41e 6,41eCT I PHONc (,� G( l� O -I 1.Z S' �or�/Z Leave s/r CFY' ST , eor FAX CONTACT NAME PHONE E-MAl STRr_c—iADDRESS I CITY,STATE, ZIP FAX ❑ OWN]t ❑ ow -BLn_czR ❑ OWNEA A= ' ❑ CON iRACTDR ❑COMMC AOR AGL T, ❑ AR== ❑-�- ❑ DEVELOPER 13 ANT CONTRACT OR NAME j`x L/9� L1C- WB ucvu rY ' I Bus.vcn COh1PANY N /ex 75L .� /�++5: I s�.ii� 'qn xl rra.c . C4 az STREET ADDRE S CITY,ST ZIP e �� PHONE /s30 , (�f Sum v yji yc _Ct CH SY4/ sc �G 8�3 ARCHTITIENGINEz'R NAM- LICENSE NLTISER BUS.LIC p COh4PANY NAME I E-MAIL FAX STR=ADDRESS I CIi Y,STATf ZIP PHONE USE OF SFD m DUPLEX ❑ MULRFAMILY I PRor=r N W^-DLAND ❑ Y-rS PROJECT IN 11YEt I IS ifs BLDG AN ❑ YES BUILDP'G: ❑COM9 LL1L URBAN U.TMCA[E' EA O ARFLOOD ZONE ❑NO EI(M_=R HOME) ❑ NO DESCRIPTION OF WORX Lo TOTAL VALUATION: /2QO, V% I RECEIVED BY: By my signature be,0, ,I criPy to each of the following: I am the pmpe—,y owner or amhori=d agent to ac:on the pop ,, owner's behalf. I have read:his application and the information I have provided is corrceL I have read the Description of Work and ve:iy it is acv—,rate. I agree:o comply with all applicable local ordiranczs and state dews relating m building gQtsp'actirn.J�uthon=mpresentadves of Cupertino to enter the above-idwtitie3 y—Lope.—,/:or inspection putyoses. Sig^-at=of Apphcant/Ag=t: //,/(�// /`// Da:e: �o 1 Z-/ f— ST,P'P'LEMIENTAL INFORMA T ION REQUIRED E USE ONLY OVER-THE-COUNTER r ❑ EXPRESS U J ❑ STANDARD U i ❑ LARGE ❑ MAJOR 1vCP:NLscApp_1011.doc revised 06/11/11 ' CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10912 LI-AVESLI-Y PI. CONTRACI'Olt:WAIATR M.SPRINGS PEIRMIT NO: 12100138 CONS'1'RUCHON OWN'EWSNAME: GALET EDWARD 1 AND KAREN I. 881 DIIRLINGA.MEA 'E DATE ISSUED: 1011712012 O\\;NER'S PHONE: 4089960762 HEll\\'OODCITY,CA 94063 PlIONF,NO:(650)592-2922 ❑ LICF.NS ED COSTTtAC1'Olt'S DIx:1,.\ItA'1-ION Ii UILDING 1'EI2Alll- INFO: BLD( f— ELECT F' PLUMB r— License Class11 Lic.q—Z _ 00 NI II 3N,��A ECH r RESIUFN'h IAL r— COMMERCIAL r Contractor P Y r,'l.5 0 Gate jU- )7-1(412. 1 hereby affirm [hill 1 am licensed unde'r4c provisions of Chapter') .1013 DESCRIPTION: REPAIR GARAGE WALL(LIKE FOR LIK I:)AND INS'I'A I.I. (commencing x'ith Section 7000)of Division 3 of the Business S 1'ndessinns NIT\ Code and than my license is in full force and effect. WA"I ER HEATER hR I hereby affirm under penalty of perjury one of the following too declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 oflhe Labor Code,for the performance of the work for which this permil is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of Lite Labor Code,for the performance of the work for which this Sq. PI Floor Area: Valuation:$15000 permit is issued. APPLICANT CERTIFICATION APS Number:35615030.00 Occupancy Type: I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and stale laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes, (We)agree to save PERI�'ll F E\PI RES 1 H YORK I$ NO I $1 t�R 1 E D indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses a'hichrally accrue against said City ill consequence oflhe NVITI-IIN 180 DAYS OF PERMI I IS.SUt1NCE OR granting ofthis permit. Additionally,the applicant understands and trill comply 18U DAYS FROM LAS") CALLED INSPEC"I-ION. with all non-point source regulations per the Cupertino Municipal Code.Section ) Issued by: �.��j v n�y� Date: A0 '/7"/ at SignureUatc'Iy 1'-�Ir(� ❑ O\YNER-I UILDF,R DECLAILATION RE ROOFS I hereby afBnn that I:un ezennpt from the Contractor's License L:nr fur one of All roofs shall be inspected prior to any rooting material being installed.If a roof is the following non reasons: installed without first obtaining an inspection.I agree to remove all ncematerials lir I,as owner of the property,or me employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business 8• I'rofess'ions.Code) Sign;nure of Applicant: Date: I,as owner of lite property,ant exclusively contracting with licensed contractors to construct the project(See.7044,Business R Professions Code). VI,1,ROOF COVERINGS TO BE.CLASS"A"OR BE ITElt 1 hereby affirm under penally of perjury line of the following three declarations: I have and will maintain a Ceniftcate ofConscnt to self-insure for Worker's HAZARDOUS MATFRIU.S DISCLOSUREa Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requircuirms under Chapter 6!95 of the performance of the work for which this permit is issued California I lealth 3 Safety Code,Sections 25505,25533•and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by conidia are frith the Cupertino 3l unicipal Code,Chapter 9.12 and the Ilealth Sections issued. ofthe Labor Codc,for the performance of the work for which this Safety Cotte.Section 2553200 should I store lir handle hazardous material. \dditin[nlly,Shot][(] 1 use rquipnu•nI lir e devices hich hazardous air pcnnil is issued' cull III ni nants as defined by the Bay At ca Air Quality Management District I will I certify that in the performance of the work for which this permit is.issucd,I shall maintain compliance t"ith the Cupertino Municipal Code.Chapter'1.12 and the not employ any person in any manner so as to become subject to the Worker's I leallh A Safety Cotte,Sections'""55115,25533,and 25534. Compensation laws of California If after making this certificate ca"exemption.I became subject to the Worker's Compensation provisions ofthe Labor Code,I mustur:nth.riz�0y_et L: / 'v„ (Z'2U/Z forthwith comply with such provisions or this perntil shall be deemed revoked. t,� •t / late: V \1'1'11(.\N'I'CGIt'I'IPIG\.LI flN. CONS RIA711ON LENDING AGENCY 1 certify that I have read this application and state that the above information is I hereby of inn that there is it construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state Iaswsrelating for which this permit is issued(Sec.3097,Cie C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property Ibr inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs-,and expenses which am%-accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ,UtCI I I'1'IiCI"S UI'C:L,UtA'I'ION with all non-point source regulations per the Cupertino Municipal Code,Seclion 9.18. 1 understand my plans shall be used 16 public records. Signature Date Licensed Professional Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 403-777-3228 C U P E RT I N O ,¢Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: p PERMIT# / OWNER'S NAME: - PHONE# -6£#Eft t CONTRACTOR: ` r n BUSINESS LICENSE# ADDRESS: ev L; CITY/ZIPCODE: Q UGC *Our municipal code require ll businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE _OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: ✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum / Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile i lo -17, zG l- Z Owner/Contractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 12 ADDRESS: 10912 Leavesley DATE: 10/17/2012 REVIEWED BY: Sean APN: BP#: 1120 'VALUATION: 1$15,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAM1IATION 1GENRES USE: PERMIT TYPE: WORK Repair garage wall like for like and install new water heater. SCOPE Meeh.Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec.Plat Check - bleed. Permit Pee: Plumb. Permit Fee: IPPFRMIT F.lec•. Permit Fee: Other,Need.Insp. .Plumb Insp. 0.0 hrs $45.00 Other Elec.Lap. El Meeh.bap.Fee: Plumb. brsp. Fee.: Flee.Insp. Fee: NOTE: This estinmte does toot inchulejees due to other Departments(i.e. Planning, Public H'orks, Fire,Sanitary Sewer District,School District,etc. . Thesefees are baser/on the prelintinan information available and are onli,an estinmte Contact die Deyajor adtln'I info, FEE ITEMS (Fee Rcvoluion 11-053 Elf. 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 = hours Plan Check, Hourly Suppl. PC Fee: Q Reg. Q OT 1 0.0 1 hrs $0.00 $0.001 1 PME Plan Check: $0.00 1 # Plumbing Permit Fee: Hourly Only? Q Yes Q No $0.00 $27.00 IPRII'11EATR Water Heater Suppl. Insp. Fee-.0 Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 Consnviction Tax: Administrative Fee: 1ADMIN $42.00 Work Without Permit? O Yes (E) No $0.00 E) Advanced Planning Fee: $0.00 0 hours Inspections E) Travel Documentation Fee: ITRAVDOC $45.00 $266.00 ISTINSP Inspection, Hourly 0 Strong MotiomFee: IBSEISAIICR $1.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $134.50 $293.00 TOTAL FEE: $427.50 Revised: 10/01/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX (408)777-3333 • buildinG(a)cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT" PROJECT ADDRESS APN9 OWNER NAME Cp n Lr I PHONE 070' E-MAIL STREET ADDRESS Q H I� CITY, STATE,ZIPV D FAX Mill ?- I_e�Vfsle P G� er�;w CR 9Sut CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX O"NER ❑ OWNER-BUILDER D OW'NERAGEM CONTRACTOR DCONTRACTORAGENI ❑ ARCHITECT D ENGINEER D DEVELOPER D TENANT CONTRACTOR NAMEWrJvtf, `'l, ; M S I �CrENSENUMHERLl 200 1 I LICENSETYPE (T BUS.LICH COMPANYNAME ll' F E-MAIL IJ FAX STREET ADDRESSl �kp 1 v 4,_e n , I CITY,STATE,ZIP �- I rt PHONE ARCHITECT/ENGTNEER NAME 11�-• LICENSE NUMBER r BUS.LIC9 / COMPANY NAME I E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK 0 ra `l l \s kV11 pr"L-p Ler e ��tc \ . ; FUST OSE PROPOSED SE� CONSTR, 4STOR}ES V (/ USE TWE OCC. SQ.FT. VALUATION(f) EXISTG NEW FLOOR DEMOTOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN 11 OTF¢R REMODELAREI REMODEL AREA I REMODEL AREA PORCH AREA DECK AREA TOTALDECIUPOKCHAREA I GARAGEAREA: UDETACH D ATTACH Y DWELLING UNITS: IS A SECOND UGIT DYES I SECONDSTORY OYES BEING ADDED'. ONO ADDITION? ONO PRE-APPLICATION OYES IF YES,PROVIDE COPY OF IS THE BLDG AN OYES $RECEIVE 'BY--: r. TOTAL VALUATION: PLANNLNGAPPL! ONO PLANNI.GAPPROVAL LETTER EICHLCRHOME? ONOC"vTE, Mvv MEN r o By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building Cons C . (authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of ApplicandAgent: ti♦r-L.-�' v (,� �i Date: fJ -1 SUPPLEMENTAL INFORMATION REQUIRED MUF-=IiItK t-- y 1e ^"�ail,��,rt_A��,ctteClzrYl'E �`��ROlIT1.CC;SCIP New SFD or Multifamily dwellings: Apply for demolition permit for e ;i ' `� t'n k `-"`tia"1 t"t*W O\ER TU&COU VERBNtDING FL4N:AEv1L\ existing building(s). Demolition permit is required prior to issuance of buildingr4e •, 'i�'"T� it, , �•� permit for new building. E} k �' tS I� `.1:ANNI"(;, GRE\9EW' _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 9O� IL STAND. D, + �O�runLlcw oxxs i To—" if any Hazardous Materials are being used as part of this project. ��• LARGEi! Y Y-,e C+ �'� FIRE':DEP '� _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. •��®�4auaox ,"• �, 4. © S�A+�tn��ipr;.i xi sEtt,Ea Dts'rRIGT Q'i e..w:t:" :."�'"�'.9❑t E\\'IRONMENTAL HEALTH - CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19500 PRUNERIDGE AVE CONTRACTOR:MIKE ROVNER PERMITNO: 12100152 CONSTRUCTION INC OWNER'S NAME: IRVINE CO—M OafJ •..CS"— 1916 DUNCAN ST DATE ISSUED: 10118/2012 OWNER'S PRONE: 5103665203 SIMI VALLEY,CA 93065 PI IONENO:(408)453-6070 . LICENSED CON fRACFOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT❑ PLUMB(J License Class_ I.ic.d 7Q5 _7ZQ r r I- n .�I IM ECH RESIDENTIAL COMMERCIAL —' Contractor Aly—e /Y/(WC- C0 4ate 10-10 )L 1 hereby affirm that I am licensed under the provisions of Chapter 9 J013 DESCRIPTION: UNIT 32 10-REPAIR ROT BELOW WATER HEATER (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 cenificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuatioii:$2000 Section 3700 of the Labor Code,for the performance of die work for which this permit is issued. APN Number:31606037.00 Occupancy Type: A PPL (CANT'CERTT FI CATION I certify that I have read this application and state that the above information is 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 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 the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands mid will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. _ 'n1 _ ) Issued by: \ell l �'� Date: Signature I ' Date o ❑ O%N'NFR-[It11LDrRDECLd RA-TION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1 hereby affirm that I am exempt from the Contractor's License Law 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 property,or my employees with wages as their sole compensation, will do the work;and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business S Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractorsto construct the project(Sec.7044,Business&Professions Code). • LI,ROOT COVERINGS TO BE CLASS"A"OR BE'I-1'ER hereby affirm under penalty of perjury one of the following three declarations: HA'LARDOUS M ATRRIAI S DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's I hmc 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 S Safety Code.Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Dl unicipal Code,Chapter 9.12 and the health S I 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 Bay Area Air Quality Management District I will P maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of Elie work for which this permit is issued,I shall health S Safety Code.Sections 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,after making this certificate of exemption,I Owner o m Illized ager r become subject to the Worker's Compensation provisions of the Labor Code,I must Datr: forthwith comply with such provisions or this permit shall be deemed revoked. CONS'1 I1C110N LENDING AGEINC1' APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I cenify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Cir 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 ARCDTTEM"S DECLARATION granting of this permit.Additionally,the applicant understands and will comply 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 t2- 1 152- GENERAL PERMIT APPLICATION M E P - C COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 950143255 MI CUPERTINO (408) 777-3228• FAX(408)777-3333• buildinQQCUDerino.org va ❑PLUMBING ❑MECHANICAL '' nn ❑ELECTRICAL ❑I.r.ISCELIANEOUS i� \� FROADDRSS I r I �1 I AFN#` Y �_ p _ J owT.ER NAME I `DIY•TvY�I I p PH014_ STRE,ADDRESS Cm, STATE,ZZ, S - I FAX CONTAR NAME PHONE q&— 3 2,C4901 `M^H-.�m r 2C - (o 'L� STI R=.uDRSS j CITY,STAT Z1? O r)l.o- 64 ❑ OWNM- ❑ OWXa- -BU7IDM ❑ OWT AGcTT ' ❑ COL-TRACTOR ACON ACiORAOMrr. ARCFT:GT ❑?•GT= ❑ DEVELOPER ❑ TIOU.T COTRSrOR NAM's - C l r LICENSE NUMBER ��� LITE TY7E �I- I HUS.LCp I�/C� V CDMPAIYNAME E-MAIL N OU � r07 r Cot—( tit "rAA Ag STILE ADDRESS CY,STATS ?HON--- —QIb CV I Q ARCIM-CTIENGIN cRNAMc LICENSENUMBEti HUS.LIE# COMPANY NAME' E-MAE. FAX STREETADDRT--SS / CITY,STATE,ZIP PHONE USE OF OSED.DUPLEX 'P& MULTLPAMD.Y I PROS INVILDLAND Q YES I PROJECT IN ❑ YES I IS Th�BLDG AN El YES BUTLDNG: CO�C UR DTERFACE NLA NO FLOOD ZONE ❑NO E]Orzk HOM*R ❑NO DESCRIPTION OF WORK Q - 3 2-ID �( TOTAL VALUATION: 2zoV RECEI cD BY: By my signature below,I certify to each of the following: I am the prope y owner or amanti ed agent to act on the propery ow;Ier's behalf. I have mad this application and the information 1 have pm-.dded is correct, I have;cad the Description of Work and veriy it is accurate. I agre;to comply with all applicable local o:diralces and state laws;elating t0 bcilding conssacdOn. I author,=repr snun,es of Cupe,Ino to enter the a/boe:.idnti5edpropr,/:or inspection pui�oses. Sigazn:re ofApplicanUA.genn Dar: SL-PPLE AI:INTFOR AA i TO 'REQUMED O-FICE USE ONLY OVER-THE-COUNTER f• ❑ EXPRESS V n ❑ STANDARD U L ❑ LAROE ❑ MAJOR .4�CP.4fucApp_2011.doc revsed 06/21/11 -