12100157 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20214CAMARDACT CONT'RACT'OR:MASTERSERV INC PERMITNO: 12100157
OWNER'S NAME: KOPELS DAVID N AND BARBARA S 560 LIBRARY ST DA'Z'E ISSUED: 10122/2012
OWNER'S PHONE: 4084611195 SAN FERNANDO,CA 91340 'PDONE NO:(800)806-7674
❑ LICENSED COMI'RACFOR'S DECLARATION 11011 DESCRIPTION: KESIUF:YI'IAL19� COMJIF,RCIAL
LJ
License Class P-SG Lic.4 S 16D0 ( 1 \ PARTIAL REPIPE IN TWO BATHROOMS
Contractor Date IV—
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following ova 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:$3997
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
,U'N Number:31624026,00 Occupancy'1}pe:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 80 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby aphorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA F OM LAST CALLED INSPECTION.
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 applicau understands and will comply Issued b)':NA, Date
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
13 ,�. RF:ROOFS:
��
Signature ? Date All roofs shall be inspected prior to my roofing material being installed.If a roof is
I installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-11111LDER DECLARATION
Signature of Applicant: Date:
I herebyaffirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR RF.TfER
I,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,
Business 6.Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUSMATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health S Safety Code.Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code.Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined b)'the Day Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the I Iealth S Safety Code.Sections 2.5505,25533.and 25534.
Section 3700 of the Labor Code,for theerformance of the work for which this
F .Owner or authorized agent: Date:
permit is issued.
1 certify that in the performance of the 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
Compensation laws of California. If,after making this certificate of exemption,I CONSI'RIICI'ION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this pemhit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANI'CERT'IFICATION Lender's Address
I certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances nihil state 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
indemnify and keep harmless the City of Cupertino against l iabilitics,judgments, ARCII ITECI"S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (�
SC
CUPERTINO (408) 777-3228 • FAX(408)777-3333• buildina0cuoerino.ora ,2 1`�� � I
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PROJ-r1TADDRESS,V)`I.� 1 . /�6r,
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Ow-NER NAME 1 . U S HOhc , I D 0— CI I` ) I� MAIl.
STP=- ADDRESS �O a . STAT¢ z8 I FAX
CONTACT NAME n PvONE t MAP
ST.Z--FADDRFSS QTY,STATE. IIP FAX
ElOW - ElOWNER-BLULDER 1-1ONWERAGZN7 11, CPOR ❑CON Ci'ORAOB-T, ❑ AR== ❑ ENG]•_ ❑ DzvSLOPER ❑ T=-ANi
CONTRACTOR NAME aD l�•r I LJCENSENUbGERI LCr7. ^T` I BUS.LJCa
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COMPANY NAME 1/! E-MAIL
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AnaREss � QTY.sTAT=_zrPC2i., I_�Nc.nrYn ZnJ I PHoNE >—�D�-'
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ARC}?fP_'Cf/FTGA'E�t NAME I
LICENSE NUN/SER 3U4.LIC i
COMPAYY NAh E-WA FAX
STRETADDRESS QTY,STATE,ZJP PHONE
VSE OF S�mDUPL:X ❑ MLJLTI-FAMILY PROJECT IN WIDLAND ❑ ]"r5 PROJAT A' ❑YES IS TIM BLDG AN El YES
BLIL II, ❑COMIfiRClA1 URBAN INT.RFACE AREA FLOOD LANE El No EIOTI—t NOME? El No
DESCR.PTLON 0-e WORK 99 II 1
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TOTAL VALUATION: rI 5. I RBCEI cD BYk
By cry signature bdow,I cer y to each of the following: I am the property owner or authorized agent to ac;on th pro eny owner's behalf. I have read this
application and the information I have provided is
comet application have=d the Dese-iption of Work and verity it is accurut I agr ec:o comply With all applicable local
ordinances and state laws relating m building cons`r don. autho=r,.pmsenmdvn of Cupeaino to enter the above-id-n6ficcd fro?e,,j for inspection put'poscs.
Sigaaru=of ApplicardAg_n[
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
❑ O<'ER-THE-COUNTER
r
- ❑ EXPRESS
V
❑ STANDARD
J
Z ❑ LARGE
❑ atAJOR
.VZP:Nua4pp_2011.don revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
:91 ADDRESS: 20214 CAMARDA CT DATE: 10/22/2012 REVIEWED BY: MENDEZ
APN: BP#: 'VALUATION: $3,997
*PERRIIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PF.NTANIATION 1RPRP
USE: PERMIT TYPE:
WORK PARTIAL RE-PIPE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS 13P FEES
Re-Pipe Interior 1PRREPIPE 2 # $26
TOTALS: F $26.00
Alech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check
Alech. Permit Fee: Plumb. Permit Fee: IPPERMIT I Elec. Permit Fee:
Orhe,- Meeh.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elce.Insp.
,Meeh.Insp.Fee: Plumb. insp. Fee: Elcr,Insp. Fee:
NOTE: This wimate doev not include jeev due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). Thave feev are bated on the prefintinan information available and are atilt'an estimate Contact the De t or addtr'I info.
FEE ITEMS (Fee Resolution /1-053 Eff LL 121 FEE QTY/FEE MISC ITEMS
Plan Check Tee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Supp/. Insp Fee
PME Unit Fee: $26.00
PME Permit Fee: $45.00
Consn'uction Tia':
Administrative Fee: ]ADMIN $42.00
Work Without Permit? 0 Yes Q No $0.00
Advanced Planting Fees:
Travel Documentation Fee: ITRA PDOC $45.00
i
Strong Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $159.50 $0.00 TOTAL FEE: $159.50
Revised: 10/01/2012