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12110068 CITY OF CUPERTINO BUILDING PERMIT RUILDINOADDRF-SS: 21979 SAN FERNANDO AVE CONT'RACT'OR:CITYOF CUPERTINO PERMITNO: 12110068 OWNER'SNADIF-: CITY OF CUPERTINO 21979 SAN FF,RNANDOAVF- DATE ISSUED: 11/132012 OWNER'S PIIONE: 4086550648 CUPERTINO.CA 95014-2823 PDONENO: ❑ LICENSED CON fRAC`fOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG (- ELECT r PLUMB r License Class Lie.H DIECII (- RESIDENTIAL r COMMERCIAL J Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALLA3'ION OF(3)GAS REGULATORS (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 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:$1500 1 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. ANN Number:35710008.00 Occupancy Type. APPLICANTCERTIFICATION I cenify that I have read this application and stale that the above information is correct.l agree to comply with all city and county ordinances and slate laws 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 againstfiabillties,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit:Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: ��/✓ �fITGiI Dale. ��•/3 9.18. Signature Date RE-ROOF'S: OWNER-BIIILDF.R 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 new materials for I hereby affirm that am exempt front the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation. Signature of Applicant: Date: will do the work,and the suucmre is not intended or offered for sale(Sec.7044, Business&Professions Code) L as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BIi1TER consir:t the project(Sec.7044,Business&Professions Code). hereby affirm under penalty of perjury one of the following three IL\%ARDOUS MATERIA-S DISCLOSURE declarations: 1 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&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 Ilealth& performance of the work for which this permit is issued. Safety Code.Section 25532(a)should I store or handle hazardous 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 Ray Area Air Quality Management District 1 will permit is issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth&Safety Code,Sections_5505,25533,and 25534. 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 Owner or a�uJhize-d agent: - Compensation laws of Califamia. If,after making this certificate of exemption,I Date: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with suchprovisions or this permit shall be deemed revoked. CONSTRl1C1'ION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CF.RTI FICTION for which this permit is issued(Sec.3097,Civ C.) I certify tliat I have read this application and state that the above information is Lender's Name correct,I agree.to comply with all city and county ordinances and state laws relating ' to building conslrction,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 liabil ities,judgments, costs,and expenses which may accrue against said City in consequence of the .\RCIII'1'FCI"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 Signal++ Cl Date 0 /Z CL- - > - I Z b 1 .:!)o (n 9- GENERAL PERMIT APPLICATION M E 1 y COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 R A ' SC GUPERTINO ^^ (408)777-3228 • FAX(408)777-3333 • buildinGlc�cuDedno.ora '\v/I MPL-UT+BLNG MECHANICAL ❑ELECTRICA.L ❑MISCELLANEOUS PROTtCTADDR ' Q - 1 "�" /I 'Ci' O'D V S0411 OWNER NAME / PHONc122RAM i ro D sTREErAD REBS cTY, STATE, FAx '0 30D /L= Avc v D 84 3 0/L/ CONTACT NAME ?HON: MAIL /1/1� Naz a 6 s5 06 I �onr W-, - S7R=7 ADDRESS CTY,STATE, ffi FAX OWNER ❑ OWNER-BUJ'ER ❑ OWNEAA�'r ❑ CONTRACTOR ❑COI+TRA=R A4-7. ❑ ARGT..CF ❑?=zZk ❑ DV_.OP R ❑ SUM CONTRACTORNAME P7 I LICENSENUMBER LICE-WSETY?E I BUS.LIC4 COMPANY NAME -.MAIL FAX STREET ADDRESS CTTY,STAT,ZIP PHONE ARCHITECTM'GA'IIt NAME / // LICENSE NIZIMER BUS.LIC i COMPANY NAW=' �'/ /•� E-MAB. I FAX STREET ADDRESS CITY,STATE;ZIP I PHONE USE OF ❑STD.DUPLE% ❑ MULTLFANCLY I PROIECTINWROLAND ❑ YS I ?ROT LN /T�YS I is THE BLDG AV 3 ❑ Y BUF U)G: MMEACAL URBAt:L"TEAFACE AAFA NO FLOOD ZONE '❑NO MCHLER HOME] NO DESCAW770N OF WORX //- S (64 7-1 0&G,45 6ULa7-62 J AA � U` TOTALVALUATION: �J/pU I RECEIVED BY: By my signature below,I ctttify to each of the following: i am the pmpcay owner or z=hon.zcd agent to act on the pmpery owner's behalf. I have:tad this application and the imonaaaon I have provided is correct I have=d the D=7ipdon of Work and vciy it is zcnsatc. I ag:ce m comply with all applicable local ordinances and state laws mlating to SnI a g consmiction. I aDdloriTD representatives of Cupeaiao toenter Lhc above-idnti5edpmpel for ipspecdon puF�asts. Signawn of ApplicantlAgenn Date: SL-PPLtMENT L INFORMATION REQUIRED OFFICE USE ONLY y OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD u z ❑ LARGE 5 ❑ MAJOR AJZPMuc9pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION Mi ADDRESS: 21979 San Fernando Ave DATE: 11)1312012 REVIEWED Bl': Sean ZMNI APN: BP#: `VALUATION: $1,500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTADIATION USE: Commercial Building PERMITTYPE: 1CMAP1 (YORK Installation of 3 as regulators. ' SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 1BAPPLOT 3 # $201 TOTALS: $201.00 Mech. Plan Check 0.0 hrs $0.00 Plnmb.Plan Check Flec. flan Check Mech. Permit Fee: IAIPFR,t11T Phtmh. Permit Fee: Flee. Permir Fee: Other Mech. Insp. 0.0 hrs $45.00 Other Plumb layOther Flee.Insp.. El ,Idech.hhsp.Fee: Month. Insp.Fee: Me.Insp. Fee: NOTE: This esiLnate does not include jeev due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School District, etc.). These ees are based on the prefinzinan information available and are onh,an estintate. Contact the De t or addn'I info. FEE ITEMS (Fee Resohnion II-053 EfC 7/1/12) FEE QTY/FEE MISC•ITEMS Plan Check Fee: SuppL PC Fee . . PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee ' PME Unit Fee: $201.00 PME Permit Fee: $45.00 Colanwetion Tux: Administrative Fee: 1ADMIN $42.00 Work Without Permit? Yes 0 No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRANDOC $45.00 Strong Motion Pee: IBSE1SMIC0 $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $334.50 $0.00 TOTAL FEE: $334.50 Revised: 10/01/2012