13020144 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10239 SANTA CLARA AVE CONTRACTOR:YBD�'ITSBE PERMIT NO:13020144 -
. QETF+RMffiED
OWNER'S NAME: ISTAK AHMMED A,�..��/ DATE ISSUED:02212013
OWNER'S PHONE: 4082301163 bitiq PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESID IAL COMMERCIAL
License Class Lic.q d'�� I S RELOCATE WATER HEATER TO LAUNDRY ROOM,
VERIFY
Contractor WaaJlrn COMBUSTION AIR VENTS
I hereby affirm that I am licensedoder the visions 0 Chopte 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:
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. Sq.Ft Floor Area: Valuation:$3000
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:32622010.00 Occupancy Type:
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 F OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accme against said City in consequence of the Issued b — %" '2 7
granting of this permit. Additionally,the applicant understands and will comply y: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. /1
RE-ROOFS:
Signature V / / 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:
I 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
I,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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Cade). I have read the hazardous 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(x)should 1 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 2550= *)
Section 3700 of the Labor Code,for the performance of the work for which this p
permit is issued Owner or authorized agent: Date
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,;atter'making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
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 such 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 a� Irl E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �\
.10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 � ' ^
CUPERTINO (408)777-3228• FAX(408)777-3333• buildinQ5,CUDertino.orG \� ■V_
PLUMBING 0MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRIS
S AIN: -,4k� 0 /O
OwN PH NE E-MAIL
na= ^�
STREET DRESS CITY, STATE,ZIP QI \6 !�h— FAX
COMACT N PHO `,J E-MAIL`
S DRES CITY,S ZIPS_ F.AX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
LICENSE ER LICENSEME HUS.LIC C
CONI J S-C A, E-MAIL FAX
S FT AD RESS CITY.STATE .'� �`� PHO
cR 231
ARCHITECT/ENGINEER NAME UCENSENIIMBER 1 BUS.LIC.Y
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFDor DRUPff ❑ MULTI-FAMILY PROJECT WWnDLAND ❑ YES PROJECT IN YES ISTHEBLDGAN ❑YES
BUILDING: COAIMERCIAl URBAN INTERFACE AREA NO FLOOD ZONE O EICHI E HOME? NO
DESCRIPTION OF WORK 10
-.-
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or auth rind aeent to act on the proplWy oamer's behalf I have read this
application and the information I have provided is correct 1 It v read the Des ' ion o and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. uthorize repr tative 'no to enter the above-i entified ropef�y for inspection purposes.
Signature of Applicant/Agent: Date:
SUP AL REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
Nr' ❑ EXPRESS
U
❑ STANDARD
U
z ❑ LARGE
❑ MAJOR
` MEPMucApp_2011.doc revised 06/27/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS:10230 SANTA CLARA AVE DATE: 02/27/2013 REVIEWED BY: MENDEZ
APN: BP#: `VALUATION: $3,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD Or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK RELOCATE WATER HEATER TO LAUNDRY ROOM VERIFY COMBUSTION AIR VENTS
SCOPE
raft- q 110-`V
.r
R.
Xtech. Mon Check Plumb.Plan Check 0.0 hrs $0.00 Eec. Plan Check
:Nccb. Pernfit Fee: Plumb.Permit Fee: IPPERMIT Elec. Perant Fee:
Other;tlech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec./nsp. Li
11-loch. Insp. Fec' Phrwb. Gup.Fee: Elec.Insp.Fine:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . Thesefees are based on the prellmina in ormation available and are only an estimate. Contact the Dent for addn 7 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Fi I # Plumbing
Suppl.PC Fee:. Q Reg. Q OT F0,0Thrs $0.00 $27.00 IPRWHEATR I Water Heater
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: 1ADM1N $42.00 O
Work Without Permit? O Yes G No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure O
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item.
Bldg Stds Commission Fee: IBCBSC $1.00
r t 133.50 $27.00 1 F T01 AIFEE $160.50
§�n=,td t $
Revised: 01/01/2013