13010024 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19967 TWILIGHT CT CONTRACTOR-TBH-468E PERMIT NO: 13010024
D&TE40.41+4BD
OWNER'S NAME: SAYRE WILLIAM L AND BONNIE L FI��) E'left..er• DATE ISSUED:01/032013' -
OWNER'S PHONE:.4082525281 PHONENO: -
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 13 OMMERCIAL
IJ
License Class^ Lie.0 EXTEND GAS LINE 16FT TO EXISTING FIREPLACE
MO-10" d
Contractor {e. Dater
I hereby affirm that I am licensed under the provisions o Chapter 9
(commencing with Section 7000)of Division 3 of the Business&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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$800
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for bre performance of the work for which this APN Number:31631036.00 Occupancy P Y n'Pe•
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 DAY SAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses whici may accrue against said City in consequence of the Issued b
granting of this permit.-Additionally,the applicant understands and will comply Y Dater �)
with all non-point soy ce rag lations per the Cupertino Municipal Code,Section
9.18. /
RE-ROOFS:
Signature �' Date All roofs shall be inspected prior to any roofing material berg 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:
1 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 BE'FPER
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(See.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). I have read thehazardous 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 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
performance of thework for whichthis 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&Safety, tior Code,See5505,25533,ar 25534.
Section 3700 of the Labor Code,for Are performance of the work for which this
Owner or authorized agent: Dater
permit is issued
I certify that in the performance of the work for which this permit is issued,I shall
not employ my person many 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 affirm that there is a construction lending agency for the performance of
forthwith comply with inch 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
GENERAL PERMIT APPLICATION �4 M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION `�
10300TORRE AVENUE•CUPERTINO, CA 950143255 �� M '
SC
CUPERTINO (408)7773228•FAX(408)777-3333•building(g)CUDertJno.Drg
93'�
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PRO=ADDRESS q `^f� I ravlt
[� cHO1I( APN# I 2I 03,L-9
OWNER NAME k—TWO
SC �(rnniY aV' lCG PHONNEY 05 _ `� �l_ V ,E-MAM
STRlEETADDRESS I WI CrFY.STATE,ZIP D Ot,^� �i4 FAX
CONTACT NAME l CC I PHONE 9
V^ -1r' 1�tMAIL
SMIMTADDRESS ( I e W .STATE, fvv� m I,P � i Q N�,,t F
1'Y /
❑ OwNER ❑ OwNT.R-BUDDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARQMWT ❑ENGAIEER ❑ DEVELOPER ❑TENANT
CONTRACTORN f q+fn ,�j Ll LICENSE TYPE BUS.LIC0
COMPANY NAME 1 GI V 1 1 1� E-MAIL FAX
STREETADDRESS Qd t ja CITY.STA _ Ap,-I PHONE
ARCHITECTIENGWEER NAME LICENSE NUMBER V�� BUS.IJC4
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CRY,STATE,ZIP PHONE
USE OF ❑SFD.DUP= ❑ muunFAMSY PRWECr DrwiLDLAND ❑ YES PROrER DI E3 YES IS THE BLDG AN [IYES
BUD.DPIG: E]cow RLTAL URBAN INTERFACE AREA FLOOD ZONE ❑NO DCHI.ER HOME? ❑NO
""'w'
ESCRIPOONOFw' /7 �n O
l� _
echc 1,ca
( 33 W
TOTALVALUATION: SJR-' REMVED 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 C I have read the Description of Work and verify it is accurate. I apr ,Io comply with all applicable local
ordinances and state laws relating to buil ' cti I author' representatives of Cupertino to enter the above-identi5edproperty for inspection put¢oses.
Signature of ApplicanUAgent Date:
SUPPLEMENTAL INFORMATION REQUIRED OF Use ONLY
y OVER-THF{OUNTER
Y ❑ EXPRESS
V
❑ STANDARD
U
❑ LARGE
❑ MAJOR
MEPMrscApp 2011.doe revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19967 Twilight ct DATE: 01/04/2013 REVIEWED BY: MENDEZ
APN: BP#: I 'VALUATION: $800
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENIAMATION 1RPGAS
USE: SFD Or Duplex : . PERMIT TYPE:
WORK extend as line 16ft to existing fireplace
SCOPE
IFw r
ilfeclr. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Stec.Plan Cherk
kfech. Perririt Fee.. Plumb.Permit Fee: IPPERMIT Elec. Pertniv Fee:.
Oihev bfech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elm Insp.
14ech.Insp. Flee: Plunda hasp.Fee: Elec.Insp. Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . These ees are based on the preliminarp in mmation available and are only an estimate. Contact the Deat for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7{ 11112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F 1 # Plumbing
Supp/. PC Fee: Q Reg: Q i OT 0.0 hrs $0.00 $67.00 IPGASRES Piping,Gas<=4 Outlets
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp:Fee-.0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: IADMIN $42.00
Work Without Permit? ® Yes Q No $0.00 O
Advanced Planning Fee: $0.00 Select a Non-Residential O
Building or Structure
Travel Documentation Fee: ITRAvDOC $45.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$133.50 $67.0014,1 ;�� 'r�+TOCALFEE $200.50
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: VAI( PERMIT#
OWNER'S NAME: Q., plesi deo -eC PHONE#
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE: 111
*Our municipal code requireiai ll 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. lz— A
I am not using any subcontractors: ' I ��Z�'
Signature Date
Please check applicable-,subcontractors and complete the following information:
j/ 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