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12090218CITY OF CUPERTINO BUILDING PERMIT RUILDING ADDRESS: 22408 BALUSTROL CT CONTRACI.OR: QUALITY FIRST PERMIT NO: 12090218 PLUMBING OWNER'S NAME: KINNEY EDWARD E 1R AND KAY B 639 DER13Y CT DATE ISSUED: 09252012 OWNER'S PHONE: 4082521956 SUNNYVALE, CA 94087 PDONF NO: (408)7331264 ❑ LICENSED CONTRACTOR'S DECLARATION .TOB DESCRIPTION: RESIDENTIAL 11 COMINIERCIAL 11 License Class- Lie. q 'C5) 'a—) PROPERTY LINE CLEAN OUT Contractor Cluj 1'(- ZL��Dnte q `ZJ —•� Z 1 hereby affirm than am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business 8 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: 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 Sq. Ft Floor Area: Valuation: $4500 performance of the work for which this permit is issued. T 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 is issued. APN Number: 35603019.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I 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 to building construction, and hereby authorize representatives of this city to enter WITHIN I DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (bile) agree to save inspection 180 DAY 111 LAST CALLED INSPECT indemnify and keep harmless the City oagainstliabilities,judgments, costs, and expenses which may accrue against said City in consequence of the /� granting of this permit. Additionally, the applicant understands and will comply, Issued by: Date:-? with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. ^ )rte Signature Date—�—�i1—/ RE-Bog m: All roofs shall be inspected prior to y roofing material being installed. If roof is an installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ % O�\'NFR- I,DFR 11 ECLARATION hereby at I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, ,V,1, ROOFCOVERINGS TO RF CLASS "A" OR BETTER will do the work, and die structure is not intended or offered for sale (Sec.7044, Business B Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to 1IA% ARDOUSSMATERIALS DISCLOSURE construct the project (Sec.7044, Business d Professions Code). I have rend the hazardous materials requirements under Chapter 6.95 of the hereby affirm under penalty of perjury one of the following three California Ilealth S Safety Code, Sections 25505, 25533, and 25534. 1 will declarations: maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I have and will maintain a Certificate of Consent to self-insure for Worker's I Icalth S Safety Code, Scction 25532(a) should I stare or handle hazardous 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 by the Bay Area Air Quality Management District I 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 Health S Safety Code, S tions .5 and 25534. Section 3700 of the Lobar Code, for the performance of the work for which this Owner ^^'' permit is issued. or authorized age Date: FrJ' I 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, 1 CONSTRU " NG 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 permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address APPLICANT CERTIFICATION' 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 upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCIII'T'F,CT"S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand m)• 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 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 VV (408) 777-3228 • FAX (408) 777-3333 • building0cuoertino.orD \�O eFfYLlJMB[NG ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS !J Q V Gt �� Qom. �'r AFNp 35w 03 01 f1 OWNER NAME PHO I E-MAIL ' STREET ADDRESS. CITY, STATE, ZIP FAX Zz vcr Lam, Tx o ,7 0 � CONTACT NAME PHONE STREETADDRESS CTrY. STATE; ZIP FAX ❑ OWNER ❑OWN/ER�BUDDER ❑ OMN AG ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGA'EER ❑ DEVELOPER ❑ TENANT CONTRACTORNAM£L� �G�y ` I_�© J1 AI LICENSE ) ERl NUC NSE TYPE BUS. LIC a COt-flM'Y NA.Vff _ E-MAIL FAX STREET ADDRESS I CITY, STATE, ZIP PHONE ARCHRECT/ENGA'EER NAME LICENSENUMEER I BUS. IJCp COMPANY NAME' E -MNL FAX STREET ADDRESS CIN, STATE, ZIP PHONE USE OF ❑ SM w DUPLEX ❑ MULTI -FAMILY PROJECT PJ W D.DIAN03 ❑YES PROJECT IN ❑ YES BUHOLNG: ❑COMMERCA. URBAN[NTERFACE AREA NO FLOOD ZONE ❑ NO is THE BLDG AN ❑YES EICHLER HOMO NO DESCRION OF WORX PTI / (� �El f❑ c_ 1 TOTAL VALUATION: RECEIVED BY: fV By my signature below, I certify to each of the following: application and the information I have provided is correct. ordinances and state laws relating to�bgco:nPtCn. Signature of Applicant/Agent: i am the property owner or authorized agent to act on the property mer•s behalf I have Toad this a read the Description of Work and verify it is accurate. 1 alit a to comply with all applicable local 1 aunze representatives of Cupertino to enter the above -identified propeml for inspection pu(poses. _ Date: ' SUP NTAL INFO R ON REQUIRED eIrIfICE USE ONLY r — 2 U U < O VER -THE -COUNTER ❑ E\f RE55 ❑ STANDARD ❑ LARGE ❑ MAJOR 1LfEP,WuGApp_2011.doc revised 06/21/11 CITY OF CUPERTINO ISI FEE ESTIMATOR—BUILDING DIVISION jAFADDRFSS: 22408 Balustrol ct DATE: 09/25/2012 REVIEWED BY: Sylvia Mech. Permit Fee: APN: BP#: 'VALUATION: 1$4,500 *PERMIT TYPE: Building Permit PLAN CIIECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: race. lisp. ree: PENTAMATION 1RPSS PERDIIT TYPE: WORK PROPERTY LINE CLEAN OUT SCOPE $0.00 NOTE: This ecrimaie sloes not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. These ees are based art lite preliminarr information m-ailable and are only soh estimate. Contact the De t or addm'I in o. FEE ITEMS (Fee Resohnion 11-053 ER' 7/1/11) Meth. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 Flec. Plan Check Mech. Permit Fee: Plumb. Permit Fee: IPPERAHT E -Ice. Permit Fee: Other ,ilech. insp. Other Plumb lisp. 0.0 hrs $45.00 Other F.(ec. /msp. El .Ilath. lasp. Fac: Phhmb. losp. Fee: race. lisp. ree: NOTE: This ecrimaie sloes not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. These ees are based art lite preliminarr information m-ailable and are only soh estimate. Contact the De t or addm'I in o. FEE ITEMS (Fee Resohnion 11-053 ER' 7/1/11) FEE QTY/FEE I MISC ITEMS Plan Check Fee: $0.00 = # $23.00 Plumbing IPRSEttER Sewer, Sanitary Suppl. PC Fee: Q Reg. Q OT 0.0 Thrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0,0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 Construction Toe: Administrative Fee: 1ADMIN $42.00 Work Without Permit? O Yes (2) No $0.00 Advanced Planning Fee:$0.00 Select a Non -Residential Building or Structure Q O Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: IBSEISAtICR $0.50 Select an Administrative Item Bld�Stds Commission Fee: Fee: IBCBSC $1.00 SUBTOTALS: $133.50 $23.001 TOTAL FEE: F $156.50 Revised: 07/01/2012