13020110 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20063 NORTHCREST SQ CONTRACTOR:AMERICAN PERMIT NO:13020110 -
RESIDENTIAL SERVICES OF CA
OWNER'S NAME: RONALD SATTUI 965 RIDGE LAKE BLVD STE 201 DATE ISSUED:0220/2013
OWNER'S PHONE: 4082531585 MEMPHIS,TN 38120 PHONE NO:(408)982-0405
❑ LICENSED CONTRACTOR'SDECLARATION JOB DESCRIPTION: RESIDENTIAL LJ OMMERCIAL
License Class / Z 1^. Lie.# ' 7G S(SS- REPLACE(E)40 GAL WATER HEATER,SAME LOCATION
Contractor JN=+ •CA feca"6116 51t'ate AZZO Lt
I hereby affirm that 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.
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 _
performanceof the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2770
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 APN Number:31638071.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I havoread 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 CALLED INSPECTIO
7.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ed Z 2�1
granting of this permit. Additionally,the applicant understands and will comply Date:
with all non-point source regulations per.the Cupertino Municipal Code,Section
9.18. - -
RE-ROOFS:
Signature= Date Z CD / 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:
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 BETTER
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(Sec.7044,
Business&Professions Code)
1,as owner of the property,aexclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
m
construct the project(See.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 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 I
performance of the work for which this 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 Code,Sections 25505,25533,and 25534.
Section 3700.of the Labor:Code,for the performance of the work for which this Owner or authorized agent:��- Date:
permit is issued:
I certify that in the performanee 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 Califomia..1 Ota making this certificate of exemption,I
becomesubject 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 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 hamiless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 1 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 \\0 M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION /1 ,0
. 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333• buildintla�cuoertino.orG \M V I M '
sc
PLUMBING 0 MECHANICAL FJELECTRJCAL / MISCELLANEODU-S
�
PROJECTADDRESS C k f�f # '� - 0 /
OWNERNAME ` r1�R P �\ E-MAIL
STREET ADDRESS N - CITY,STATE,JZIP FAX
ZG06 VI0("*' Crav 60-J* C'VloerArII^o cA WOM
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BIIIDER ❑ OWNEtAGENT NIRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS.LIC#
R 4e�, cs sY C sok e r
COMPANY NAME -BSCVR - C *"XXIZLG E-MAIL FAX
STREET ADDRESSCITY STATE,ZIP ONE
2305 art; 0,, iX Sc • e �� 9�sz-os�r
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COWANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMLY PROJECT IN WI1)LAND ❑ YES PROIECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COt.B.ffRCIM. URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICH:Um HOME? ❑NO
DESCRIPTION OF WORK
(A(E d F\ 1/VIGY IBCA
TOTAL VALUATION:
By my signature below,I certify to ellch of the following: I am the property owner or authorized agent to act on the property s behayA have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I—authorize representatives of Cupertino to enter the above-identified propetly for inspection putposes.
Signature ofApplicza t/Agenn Date: —Z6O/y-->
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
L
❑ EXPRESS
Y
U
❑ STANDARD
U
❑ LARGE
L
❑ MAJOR
MEPMacApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20063 NORTHCREST SQ DATE: 02/20/2013 REVIEWED BY: MELISSA
EPN: 316 38 071 BP#: `VALUATION:*PERMITPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or DUPI6x PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK REPLACE E)40 GAL WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $27
TOTALS: $27.00
A.
- lrfech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Chock
ibfech. Permit Fee: Plumb.RPermit Fee: IPPERMIT Glee. Permh Pee:
Other biech. Insp. Other Plumb Insp. hrs $45.00 Other Elec.Insp.
Heck Insp. Fee: Plumb. hup.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 eta). These fires are based on the prelindn in ormation available and are only an estimate Contact the Dept for addn 4 info.
FEE ITEMS (Fee Resolution 11-053 E 711/121 FEE QTY/FEE MISC ITEMS
Plan Chuck Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Perinit Fee:
Suppl. hv.sp Fee
FA
PME Unit Fee: $27.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: IADtts[N $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bide Std s Commission Fee: 1BCBSC $1.00
M T
$
iu'"'4¢ !Lff 5 ; `rl�ny4 r t $160.50 ,,$0.00 i ;� To E ' 160.50
evised: 01/01/2013
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 m- -cans shall be used as-ublic re---'-