12120082 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19661 LA MAR DR CONTRACTOR:13A'I11 I-TI-11R NOR'I'l TERN PERMIT NO: 12120082
CALITORNIA
OWNER'S NAME: KAYE CAROLINE J AND I IAROLD 11 2118 ZANKER 121) DATE ISSUED: 12/17/2012
OWNER'S PHONE: 4082579629 SAN JOSE,CA 95133 PRONE NO:(408)834-1111
LICENSED CONT'RACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Classic.4 � 03 _�
� MECII RESIDENTIAL COMMERCIAL.
Contractor Date7//-2,
1 hereby affirmrhastiti
m licensed under the provisions o Chapter 9 JOB DESCRIPTION: REPLACE SIIOWEWTU13 MIXING VAI.VI:
(commencing won 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 sell'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:$1400
f 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. APN Number:36910017.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that l 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
elating PERMIT EXPIRES IF WORK IS NOT STARTED
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, 180 DAYS FROM LAST CALLED INSPECTION.
costs.and expenses which may accrue against said City in consequence of the
granting of this per onally,the applicant understands and will complywith all non-point r r la' ns per the Cu rtino Municipal Code,Section Issued by Date-//Z -17'
9 18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed. It'a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from 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 structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1•as owner of the property,am exclusively contracting with licensed contractors to AL1.ROOF COVERINGS TO BE CLASS"A"OR 13H;f"hER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three ITAZARDOI S 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 sell'insure for Worker's California health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 ofthe 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 Bay Area Air Quality Management District I will
permit is issued. maintain c plianee with the Cupertino Municipal Code,Chapter 9.12 and the
lleallh ode,Sections 25505,25533,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 Oivne r riz --7� �`t�-
Compensation Taws of California. If,after making this certificate of exemption, I _ Date;
become subject to the Worker's Compensation provisions of the Labor Code,I most
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of'work';
APPLICANT CERTIFICATION 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. 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 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 ARCHITECT'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
SG";-_-Xi i �
GENERAL PERMIT APPLICATION P
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333-buildingacuoerGno.ora misc
"LING�fMECHANICAL ORYMMCAL MISCEL/LAANEOUS
PROJECT ADDRESS I ILA AI— -DInV9
APN i
OWNER NAMEQ / V - Fx `J��`-2 p 0,1 E- IL
STREET ADDRESS /V
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CONTACT'NAMki 4-r-E PHONE '�►1/ }•t
E-MAIL
STREETADDRESS CITY,STATE, ZLP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAOENT CONTRACTOR ❑CONTRAcroRAGENT ❑ AtcmTwr ❑I3NGDm ❑ DEvELopsm ❑TENANT
CONTRACTOR NAME LICETISE ER II 7vpg # ��
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GO ANY NAME
E-MAIL
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STREET ADDRESS CITY.STATE,ZIPSkTi CA q5k -9-.2,4-1t�1
ARCHITTCT/ENONIM NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRBSS CITY,STATE,ZTP PHONE
USE OF orounEx ❑ MULTI FAMILY PROJECT IN WMDLAND ❑ YES PROJECT IN ❑YES LS THE BLDG AN ❑YES
MWING: ❑COMMERCIAL URBAN D+ E WACE AREA p No FLOOD ZONE ❑No Em3amt Homm ❑No
DESCRIPTION OF WORK
(49 -IN - (Ln-tL-( Mj' &)--rY4 �AV
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A.
=.4L VALUATION: !�5 CoRECELVED BY:
I3y my signature below.Iy to each of the foIlowiag I am the property owner or authorized agent to act on the property owner's behalf I have read this
application and the khmation I have is correct have read the Description of Work and verify it is accurate. I
ordinatices and state Taws relatingto � agree to coasply with all applicable local
I authorize representatives of Cupertino to eater thq above-i ed fbr inspection poses.
Signature ofAppl cant/Ageat Daft: .Z
AL INFORMATION REQUMM OFFICE ONLY
6—OVER-TIM-COUNTER
a,
❑ S7CPRFSS
❑ STANDARD
Q
❑ LARCE
❑ MAJOR
MEFA&cApp 1011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 19661 la mar dr. DATE: 12/17/2012 REVIEWED BY: Sean
APN: BP#: ,d-IL—,�-620(gam "VALUATION: 1$1,400
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPFIX
USE: PERMIT TYPE:
WORK Replace shower/tub mixin-q valve.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixture or Trap 1BPFIXTURE 1 # $10
TOTALS: $10.00
14"<_1r. 1"'a"t'i,<cA Plumb.Plan Check FO.01 hrs $0.00 lice. f'/Wz Chc<h
{,lcn it. Perm t 1'c> Plumb.Permit Fee: IPPERMIT l;l<a- t't:r:+rill V1f,:
t)Nx v alec°1a. 1"I" Other Plumb Insp. Fo hrs $45.00 Utr'rr t 1,1Cf,_I»s1r. El
alccn. 11s'u. I"v, 1r;x1z t
NOTE. This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Thesefees are based on the prelimina information available and are only an estimate Contact the Dept/or addh 7 info.
FEE ITEMS(Fee Resolution 11-053 Cff 7/1112) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
P r;nit 1`cc.
;Saspp/J 111s , F'e�
PME Unit Fee: $10.00
PME Permit Fee: $45.00
t�c�szstsuciion 1 crf:
Administrative Fee: (ADMIN $42.00
Work Without Permit? 0 Yes E) No $0.00
c-�1'CJIIC't'tt P/CfX7fN1010j FCC`:
Travel Documentation Fee: ITRA VDOC $45.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldy,Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $143.50 $0.00 TOTAL FEE: $143.50
Revised: 10/01/2012