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13010135I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 887 ALDERBROOK LN OWNER'S NAME: WILSON EVA F CONTRACTOR: r,7 zee /'IAN1u7 I PERMIT NO: 13010135 B&I I d e-ok DATE ISSUED: 01282013 htvNER'S PHONE: 4082536662 1 , 1 f HONE NO: LICENSED CONTRACTOR'S DECLARATION License Class ic. p :70 Contractor Date 1 hereby a mm th 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. 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. 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. 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, 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 re ulations p r the Cupertino Municipal Code, Section 9.18. Signature fl Date ❑ OWNER- BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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 (Sce.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to concoct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1 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. 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. 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, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correc(. 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 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 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date JOB DESCRIPTION: RESIDENTIAL REPLACE (E) WATER HEATER, SAME LOCATION Sq. Ft Floor Area: I Valuation: $1000 I APN Number: 36920007.00 I Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: bC i" t,-- Date- / - IF-)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, 1 agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cuper 5no Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 255 , 25 3 nd 25534. y� Owner or authorized agent: D CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildina(a)cuoertinO.OrD Ri PTJTMRTNR I— IMF.('HAMCAL I— (ELECTRICAL I— (MISCELLANEOUS MEP MISC PROJECT ADDRFST P1 OO C lQ -ove AFN" 36 Zo oo W ME I PHONE �O EMAIL STREET ADDRESS CITE STATE, ZIP SO/ C I O FAX CONTACT NAME PHONE E-MAIL STREETADDRESS CRY, STATE, ZIP FAX ❑ OWNER ❑ OWNER- BUDDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME p O ur // 04" tr IQref LC S6 NUMBER O f LICENSE TYPE BUS. LIC a COMPANY NAME o E NN BIVC OUr✓O U:I�e&r.Cd^ FAX STREET � DRESS ` a SCC ( CRY. STA c-,( 9 S D O S y07 Jo s- r �o G ARCHMCT04CWM NAME LICENSE NUMBER BUS. UCa COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD ar DUPLEX BUILDD40: COMMERCIAL ❑ MULTI - FAMILY PROJECT DJ WI DLAND ❑YES URBAN INTERFACE AREA 0 NO PROJECT DJ ❑ YES FLOOD LANE ❑ NO IS THE BLDG E? ❑ NO EICTiLFA HOME? ❑ NO DESCRIPTION OF WORK l TOTAL VALUATION: / DD RECEIVED BY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is L I h e d the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building ction. 1ze represrntativu of Cupertino to enter the above -idea ified pro for inspection puijjoses. Signature of ApplicanVAgent. Date: —SUPPLENgINTAL WFORMATIONREQUIRED OFFICE USE ONLY y ❑ OVER - THE - COUNTER Y ❑ EXPRESS V U ❑ STANDARD J ❑ LARGE C ❑ MAJOR MEPMucApp_2011.doc revised 06121111 �� . CITY OF CUPERTINO I �' // FEE ESTIMATOR - BUILDING DIVISION �c�i ADDRESS: 887 Alderbrook DATE: 01/2812013 REVIEWED BY: RDW UNITS AP BP#: *VALUATION: $1,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $27 PENTAMATION PRWHEATR PERMIT TYPE: WORK a lace water heater SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check Fo .0 hrs $0.00 QTY UNITS BP FEES Water Heater T ..,. ,.:,; 1 # $27 trrmit Fee: ;nppl. Av.sp Fee PME Unit Fee: $27.00 PME Permit Fee: $45.00 . onswur Lion 71n. Administrative Fee: $42.00 Work Without Permit? O Yes Q No $0.00 TOTALS: Travel Documentation Fee: $27.00 Strong Motion Fee: &SEISAHCR NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works. Fire, Sanitary Sewer District, School Dicrrirt. err_ h These lees are based an the mreliminary information available and are onlv an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11 -053 E/f 711112) FEE Plumb. Plan Check Fo .0 hrs $0.00 MISC ITEMS 'lnn Check Fee: Plumb. Permit Fee: IPPERb117 4uppl. PC Fee Other Plumb Insp. 0.0 hrs $45.00 ..,. ,.:,; Plamh. h'y. Ic, $0.00 NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works. Fire, Sanitary Sewer District, School Dicrrirt. err_ h These lees are based an the mreliminary information available and are onlv an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11 -053 E/f 711112) FEE QTY /FEE MISC ITEMS 'lnn Check Fee: 4uppl. PC Fee PME Plan Check: $0.00 trrmit Fee: ;nppl. Av.sp Fee PME Unit Fee: $27.00 PME Permit Fee: $45.00 . onswur Lion 71n. Administrative Fee: $42.00 Work Without Permit? O Yes Q No $0.00 Advanced Plunnin,Q Fees: Travel Documentation Fee: $45.00 Strong Motion Fee: &SEISAHCR $0.50 Select an Administrative Item Bldg Stds Commission I'cc. IBCBSC $1.00 SUBTOTALS: 1 $160.50 $0.00 TOTAL FEE: $160.50 Revised: 10/01/2012 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: / 417,7av S ecn Vo d'W1 BUSINESS NAME PERMIT # f 3-O F O t 3S OWNER'SNAME: fua al sooj PHONE# GENERAL CONTRACTOR: Xlue A2ue,., QY r rrr s BUSINESS LICENSE # ADDRESS: ®S.7 Al re za o /r' `a v c. CITY /ZIPCODE: *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 SU ONT TORS HAVE OBTAINED BUSINESS LICENSE. I am not using any subcontractors: ignature Please check applicable subcontractors and complete the following information: k CITY OF CUPERTINO —1h 8 Date 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