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13020020CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22276 HARTMAN DR - CONTRACTOR: MIKE COUNSIL PERMIT NO: 13020020 - - PLUMBING INC OWNER'S NAME: FROLICH DONALD A AND ROSALYN 1915 O'TOOLE WAY DATE ISSUED: 02/052013 OWNER'S PHONE: 4082453243 SAN JOSE, CA 95131 PHONE NO: (408) 2724900 2( LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ OMMERCIAL License Class C ?(o Lic. # U7q )--(P 1 REPLACE (E) WATER HEATER, SAME LOCATION & REPLACE Contractor Mly+, C (AJ ,22IL .PI.Un10j , 2 S • (E) WATER SERVICE FROM METER TO HOME (f O WORK I hereby affirm that I am licensed under the provisions. of Chapter 9 IN (commencing with Section 7000) of Division 3 o the Business & Professions THE PUBLIC RIGHT OF WAY) 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $5000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32613086.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS F AST 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 Issue ate: granting of Uri emit. Additionally, the app cant understands and will comply with all non-poin so ce re p e. rtino Municipal Code, Section 9.18. Signature Date 2.5 -�3 RE -ROOFS: 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 inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or myemployees with wages as their sole compensation, will do the work, and the structure isnot intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I 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 1 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 Q ity Management District 1 performance of the work for which this permit is issued. will maintain compliance wit Cupertino Muni 1 Cade, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, S ctio s 5 , 55 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date. -2 5 •(3 permit is issued. 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirn that there is a concoction 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 APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, 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 El GENERAL PERMIT APPLICATION O6 V� M E P COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255�'S ^ (408) 777-3228 • FAX (408) 777-3333 • buildingQCUoerlino.org V1 ■v_ �CAT.1amTNr; nMECHAMCAL 7ELECTRICAL I— NffSCELLANEOUS PROJECTADDRESS ^ n Z� LfJ APNI ('3 IO OWNER NAME PHONE7 E-MAIL STREET ADDRESS 222 CRY, STATE,Z� S FAX CONTACT NAME �� PHONE iag cl`LJ S^ YJ E-MAIL STREETADD SS Ave CITY, STATy te` CA v�jg FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT Jb CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT IXJNTRACI'ORNAME LICENSENUMBEER LICENSEOS BUS. LIC# COMPANY NAME Yri E-MAIL FAX 5 Ec ADDRESS CITY, STATE ZIP VISI PHONE 2`72 t -'i ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑CONNIERCIAL PROJECT IN WILDIAND ❑ YES='T URBANINTERFACEAREA ❑ NO AOIECT IN ❑ YES FL 'TON,, ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK L/ TOTALVALUATTON:(f(�(% ' By my Signa ure below, I cert fy each f followi . Is the prop owneror authorized agent to act on he property or i a f. I have read h s application and the information I ave p vi is et, ba d ascription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin to but onsl ction dio esentatives of Cupertino to enter the above-identifiedpropeti'y for inspection puf�oses. Signature of Applicant/Agent Date: Z -.457 ' 13 SUP LEMENTAL INFORMATION REQUIRED OFFICE USE ONLY W OVER-THE-COUNTER Y ❑ EXPRESS U U ❑ STANDARD ❑ LARGE ❑ MAJOR MEPMucApp_2011.doc revised 06/21/11 ��.��,�,� CITY OF CUPERTINO W— I FFF FCTiMATnR _ RITii,nING nIVTS10N LaADDRESS: 22276 HARTMAN DR DATE: 02/05/2013 REVIEWED BY: MELISSA UNITS i APN: 326 13 086 BP#: *VALUATION: $5,000 *PERMIT�TYPE: PlumbingI Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD Or DU lex p $27 PENTAMATION PRWHEATR USE: 1BPWSVCS PERMIT TYPE: WORK REPLACE E WATER HEATER SAME LOCATION & REPLACE E WATER SERVICE FROM SCOPE METER TO HOME (DO WORK IN THE PUBLIC RIGHT OF WAY) APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $27 Water Service 1BPWSVCS Suppl. Insp Fee 1 # $23 PME Unit Fee: $50.00 PME Permit Fee: $45.00 Consiruction Tax: Administrative Fee: ]ADINN $42.00 Work Without Permit? Q Yes Q No $0.00 TOTALS: ��< ' n. 4 $50.00 Strong Motion Fee: IBSEIS,NICR $0.50 Mee/?. Plan Check I I Plumb. Plan Check 10.0 1 hrs $0.00 Flee. Plan Check Mech. Penni! Fee: Plumb. Permit Fee: IPPERMT I Elec. Permit Fee: Ocher Afech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Ocher Glee Insp. Heck Insp. Fee: Plum ). Inep. Fey,. Elec. Insp, Piece NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer Disc FEE ITEMS (Fee Resolution -]!-053 Eff. 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee PME Unit Fee: $50.00 PME Permit Fee: $45.00 Consiruction Tax: Administrative Fee: ]ADINN $42.00 Work Without Permit? Q Yes Q No $0.00 Adwinced Plamcing Fees: Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion Fee: IBSEIS,NICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $183.50 $0.00 i '," ? `TOALFEEaT $183.50 �\ Revised: 01/01/2013 CUPERTINO CONTRACTOR/ SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS:22 (p PERMIT# . OWNER'S NAME: Ttmadj It4 A U4 PHONE # Ll -2,12 IJD GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: Z CITY/ZIPCODE:_: *Our municipal code requires all businesses working hi the city to have a'City of Cupeitino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSP CTION(S) . WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND 4f-L\,SUBCONTRACTORS HAVE OBTTAINED-°A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: 2'✓�' �� Signature Date Please check applicable subcontractors and complete the following irtformahon:=_; Owner / Contractor Signature Date 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