12120081 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22753 VOSS AVE. CONTRACTOR:BATH I ►-TITTER NORTI IERN PERMIT NO: 12120081
CALIFORNIA
OWNER'S NAME: JAMES&CLAUDETI PRE'fTYLEAF 2118 ZANKER RD DATE. ISSUED: 12/17/2012
OWNER'S PHONE: 4083078313 SAN JOSE,CA 95133 PHONE NO:(408)834-1111
LICENSED CONTRACTOR'S DECLARATION i— �
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License ClassI ic.# (�
MECRESIDENTIAL COMMERCIAL
ContractorMDale �—
1 hereby affi tat I am licensed under the provisions of Chapter 9 JOI3 DESCRIPTION: UNIT[3-REPLACE SHOWER/"l'[1B MIXING VALVE
(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 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 FloorArea: Valuation:$1400
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. APN Number:34230034.00 Occupancy Type:
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 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 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 perm . Additionally,the applicant understands and will comply
with all non-point s rc r ations per the Cupertino Municipal Code,Section — Z ?
—� —�'
9 18 Issued by:�.— �—� Date.
/Z
Date
RE-ROOFS:
❑
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed- 11'a roof is
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
i
the following two reasons: inspecton.
I,as owner ofthe 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS 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 health&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 health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Addifionally,should 1 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 Arca Air Quality Management District 1 will
permit is issued maintain yompliance with the Cupertino Municipal Code,Chapter 9.12 and the
411ealtha deSections 255(1.>,2SS33,and 25534.
I certify that in the performance of the work for which this permit is issued,I shallnot employ any person in any manner so as to become subject to the Worker's t: /
Compensation laws of California. I1,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 such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCI'
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CE RTI EICATI0N 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 ►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
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
MEP
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•Wlding(ftupertino.oro misc
L ING MECHANICAL. DMECIMCAL CIMISCMLANEOUS
PROIECf ADDRESS Q S� �6 AM# `/ !p�- �3 0
OWNFRNAME (� PHONE
E-MAII.
STREET ADDRESSc4375 D5 /Iv-c— ML4ALZ4NiftoO`¢ FAX
CONTACT NAME n` PHONE
},n 1 E-MAII.
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT camRACTOR ❑cmm.ACrORAGENT ❑ AxammCT ❑ENGDim ❑ DEvmoPBR ❑TENANr
CONTRACTOR NAME u�f isSE
s[JS *
Z
CO
[ ANY
E ,
✓
STREET ADDRESS CTIY,STAIF,ZJP
ARCI]TECTANGI MEEK NEANIE LICEPISE NUMBER HUS LIC N
COMPANY NAME' E-MAM FAUX
STREET ADDRESS art,STATE,z PHONE
USE of a DUPLEX ❑ MULTI-FAMn Y PRWECT IN WM AND ❑ YES PROTECT TNI ❑YES LS THE BLDG AN ❑YES
BUnzwc ❑c magma L FURBAN DJTERFACE AREA ❑ NO FLOOD ZONH ❑No E MER HOME? ❑No
DESCRIPTION OF WORK
'R
U n
TOTAL VALUATION: RECEIVED BY: ��
B3'my si8nature below,I certify to each f the following I am the property owner or andtorized agent to act on the property owner's behalf I have read this
application and die information I have have read Description of Wont and verify it is aeemste. I agree to comply with all applicable local
ordmances and state laws relating to din representatives of Cupertino to enter tho above-idpecd Voperrf fur inspection p4Oees,
Signature of Appl cant/Agent Date: L Z,
15UWLTAL INFORMATION REQUIRED OmCE USE ONLY
w OVER-THE-COUNTER
❑ EXPRESS
_ ❑ STANDARD
V
❑ LARGE
❑ MAJOR
MBPA&cApp 1011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 22713 Voss Ave �)4/-/- 6 1 DATE: 12/17/2012 REVIEWED BY: Sean
APN: BP#: 1A Z,2 m-q / *VALUATION: 1$1,400
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPFIX
USE: PERMIT TYPE:
WORK Replace shower/tub mixing valve.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixture or Trap 1BPFIXTURE 1 # $10
TOTALS: $10.00
Lfech. I'lurt t rt rk Plumb.Plan Check 0.0 hrs $0.00
1-1c 1 i�, A:rw 'f"; Plumb.Permit Fee: 1PPERMIT F"I"
Other Plumb Insp. 0.0 hrs $45.00 oilhu,0< b"I'll.
f'himh. h_;E;, F'
NOTE. This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelimiina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff711!121 FEE QTY/FEE MISC ITEMS
Plan C hcrc/c
Suppl. PC FCC,
PME Plan Check: $0.00
Pet-rnit Fcc:
.Salop/. Dash ""Cc,
PME Unit Fee: $10.00
PME Permit Fee: $45.00
Construction Tax., F
Administrative Fee: IADMIN $42.00
Work Without Permit? Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $45.00 A
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $143.50 $0.00 TOTAL FEE: $143.50
Revised: 10/01/2012