12100207 CITY OF'CUPERTINO BUILDING PERMIT
BIIILDING ADDRESS: 21430 COLUMBUS AVE CONTRACTOR:IIATI'I FITTER NORTHERN PERMIT NO: 12100207
CALIFORNIA
OWNER'S NAME: SKEELS V DEAN AND SALLY A TRUSTEE 2118"/-ANKER RD DATE ISSUED: 10292012
OWNER'S PIIONIi: 4086916783 SAN,JOSE,CA 95133 PHONE NO:(408)834-1111
LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG (- ELECT 171 PLUMB r
License Class t D Lic.0 �(J3 J /3 r r-! M
MECFI RESIDENTIAL COMMERCIAL
Contactor Datc o -Z
I fir a d
hereby afi t 1 oat licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD SHOWER VALVE AND NEW SfIOWER PAN;NO TILE
(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,at provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq. Fr Floor Area: Valuation:$5000
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. AI.N Number:36205004.00 Occupancy Type:
,%PPI.ICAN"1'CER'1'IpICA'1'ION
I certify that 1 have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state lases relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize 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, I8� DAYS FROM LAST CALLED INSPECTION.costs,and expenses which may acerae against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point urce regulations per the Cupertino Municipal Code,Section Issued by: &7A, Date:
9.18.
Signature Date lO a 1 Z
RE-ROOFS:
❑ O%VNIiR-RUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed w•ithma first obtaining mm inspection.I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Lawlor one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages M their sole compensation, Signature of ApplicanC Date:
will do the work,and the structure is not intended or offered for sale(Scc.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to A LI-ROOF COVERINGS TO BE CLASS",x"OR BET FE.R
construct the project(Sec.7044,Business R Professions Code).
hereby allirm under penalty of perjury one of the following three IIA"LARDOUS 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 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 I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Addi(innxlly.should 1 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 Hay Area Air Quality Management District I will
ermit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
F Ilcalth S Code.Sections 25505.25533,and 25534.
afety
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 (teener a 14 ze `u r
Compensation laws of Cal ifomia. If,after making this certificate of exemption,1 (late:
become subject to the Worker's Compensation provisions of the Labor Code,I most
forthwith comply With such provisions or(his 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 CERT'IFICAT'ION 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.1 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,
costs,and expenses which may accrue against said City in consequence of the ARCI I ITECI"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
c-..)j — 1 2 � c,(-->
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 � '
CUPERTINO (`08)777-3228• FAX(408)TT7-3333• buildinggIcuoertino ora
LUMBING MECHANICAL FlaWMCA.L. ❑MLSCELIANEOUS
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CONTACT NAME
E-MAILRHONE
STREETADDRFSS _ CTTI',STATE, Z@ FAX
❑OWNER ❑ OWNER-BOIIDFA ❑ OWNERAOFJYT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCEM= ❑Ql@IM ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME r LICENSE ER V Typ )R)S, tl r/7
fO ANY NAME
/I E-MAIL
-1112
S[AFf7 ADDRESS QTY,STATE,ZIP C S I
ARCH=/ENOOMM NAME UMSE NUMBER .BUS LIC a
COMPANY NAME' E-MAIL FAX
STREET ADDRESS QTY.STATE,AP LnHM
USE OF QOUPEFS ❑ MVL7SFAMlLY MQWTN WITDLWD ❑ Y6 PRO=W ❑YLS l)O AN ❑YES(nR1DNO ❑COMMFRQAL IIReA]iDRERFAtEAAPA ❑ NO FLOW ZO ❑NO HOmm ❑NO
OESCs1MON OF WORK
Mk Xj
TOTAL VALUATION: D
REQ3VED BY:
BY MY sigrmmre below,I certify m cash of the following: I ata the property owns or anthoriZed agent m as on the property owner's behalf I have rad this
application and the i�btmatioo I have is read the
mdm and stare laws relating m ti ' I mnhm>u Dtsmptiw of WorkCUP&and verify it h above a. I ages m cor�lY with cap applicable local
� tarives of CbpctiDo m eater the about-i '
Signature:ofAppfirmt/Ageot
Due: --
p AL WFORMATION REQUIRED
�q OFFICE USE ONLY
u p OVER-THE-COUNTER
a
❑ E FRFM
❑ STANDARD
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❑ KAJOR
AEPAitcApp 2011.docrevisedO6/11/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
12.1 ADDRESS: 21430 Columbus DA'Z'E: 1 0/2 912 01 2 REVIEWED BY: gs
APN: BP#: 'VALUATION: $5,000
`PERMIT TYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration/Addition / Repair
PRIMARYPENTAMATION
USE: SFD or Duplex PERS\117•'1'l'1'E: At
1RPFIX
wORK Add shower valve and new shower pan. no tile.
SCOPIi
APPLIANCE/EQUIPTYPE FEE ID QTl' UNITS BP FEES
Fixture or Trap 1BPFIXTURE 2 # $20
TOTALS: $20.00
Rech Phan Check Plumb. Platt Check 0.0hrs $0.00 Lha. Tkaa Choc k
,Narlr. I'r:rmil Fee: Plumb. Permit Fee: /PPER,1117' Ahro.Perndt Fes•
Other A/ech. beep. Other Plumb Insp. 1.0 hrs $45.00 Other Elcs.hip. El
Aleeh./Ay, Pee: Plumb. Insp. Fee: 1PLAIBINSP $133.00 hler.harp. Fee:
A'071: This estimate does not include fees clue to other Departments(Le. Planning, Public Works. Fire,Sanitary Sewer District,School
District.etc.). These fees are haled nn the prelintinan•in arntation available and are only an esthuate. Contact the Dept for aaldn'I info.
FEE ITEMS tLce Resolation 11-053/ . 7/1/'11 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
S'uppl. PC Fen:
PME Plan Check: $0.00
Permit Fee:
Snppl. Ilkip Fee
PME Unit Fee: $20.00
PME Permit Fee: $178.00
Construction Tax:
Administrative Fee: IADAIIAa $42.00
Work Without Permit? O Yes 0 No $0.00
Ath•anceelPlanning Fees:
Travel Documentation Fee: ITRAFDOC $45.00 A
Strong Motion Fee: IBSEISAOICR $0.50 Select an Administrative Item
131cte Stcls Commission Fee: IBCBSC $1.00
SUBTOTALS: $286.50 $0.001 TOTAL FEE: 1 $286.50
Revised: 10/01/2012
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
JOB ADDRESS: U 01 PERMIT#
OWNER'SNAME: jl eel PI-IONS # r,-- 91 - 07&3
GENERAL CONTRACTOR: BUSINESS LICENSE # 737 5'6'
ADDRESS: p/ CITY/ZIPCODE: Scvi 15z ( S/
*Our municipal code requires all 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 S BCON - CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
am not using any subcontractors: 11fie / 01A 9 !0�
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
Owner/Contractor Signature Date