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11040100 CITY OF CUPERTP_ O BUILDING PERMIT BUILDING ADDRESS: 10400 JOHNSON AVE CONTRACTORS lff5-� PERMIT NO: 11040100 OWNER'S NAME: LEON TOREY ACT)'S p u DATE ISSUED:04/15/2011 VNER'S PHONE: 4084464718 y PHONE NO: L{d'VNLICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE] License Class `5(e Lic.# `/5,13 O 1- INSTALL WATER HEATER AT EX OUTDOOR CLOSET Contractor,/�f�f�r/.5 ��{(6Y��f/'�r'7 Date 4' /5/ /r 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$995 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:37526052.00 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ¢/ Date: granting of this permit. Additionally,the applicant understands and will comply Issued by:_ '`% � with all non-point source regulatio er the Cupertino Municipal Code,Section 9.18. 1-15ZX RE-ROOFS: Signature Date 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. 0 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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) 1,as owner of the property,am exclusively contracting with Iicensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.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 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 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 3503,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen �7 Date permit is issued. 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,after 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 neon the above mentioned property for inspection purposes.(We)agree to save .mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION .,ts,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 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37526052 . 00 DATE ISSUED. . . . . . . : 04/15/2011 RECEIPT #. . . . . . . . . : BS000013192 REFERENCE ID # . . . : 11040100 SITE ADDRESS . . . . . : 10400 JOHNSON AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LEON TOREY ADDRESS . . . . . . . . . . : 10400 JOHNSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : VICTOR MARTINEZ CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 995 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 995 . 00 0 . 50 0 . 00 0 .50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0. 00 1PRWHEATR UNITS 1 . 00 25 . 00 0 . 00 25 . 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 110.50 0 . 00 110 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 110 .50 110 .50 --------------- TOTAL RECEIPT 110 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10400 johnson ave. DATE: 04/15/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $995 ';PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/Repair PRIMARY SFD or Duplex PENTAMATION PRWHEATR USE: I PERMIT TYPE: WORK install water heater at existing outdoor closet. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $25 TOTALS: $25.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.00 NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee Resolution 09-051 Eff. 7-1-10) FEE QTY/FEE MISC ITEMS 77 1 PME Plan Check: $0.00 PME Unit Fee: $25.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item L ldg>,Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $110.50 $0.00 TOTAL FEE: $110.50 Revised: 01/15/2011 Building Department City Of Cupertino La 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 Ot JOB ADDRESS: '0 elt7e-' PERMIT# OWNER'S NAME: C f�/✓ 7T�� ' PHONE# GENERAL CONTRACTOR: etc/t7e-rt.7 BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all 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 HAV OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: ' � Signature Date Please check applicable subcontractors and complete the following information: V 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 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE- CUPERTINO, CA 95014-3255 CUPERtINO (408)777-3228 • FAX(408)777-3333-buildingCc cupeMno.ora misc PLUMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS !6/06 PROJECT ADDRESS k // 1 n b `Jvf�to aAPN ve v't-- �� 5 OWNER NAME PHO E-MAIL STREET ADDRESS L G I r✓ «�� V C j7/� CITY, STATE,ZIP FAX0-`7- 61 Ut'L -`TI NC3 - ,4 CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC It i G'TZ _ /l *A/Z T N COMPANY NAME E-NWB. FAX ti �R films F, �C ivt/�iN C i j�n v iCt lir f}i� T iso u a 2 r3t�'FriK�7iu STREET ADDRESS CITY,STATE,ZIP PHONE 15315'? f r`Gt i2 T/d ry C 7 c_ fr7�' 1 r7 7 ') -�.,a' ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC H C ONTANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE iSE OF SFD or Duplex ❑ Multi-Family PROJECT IN WB.DLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN GMWACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK /AJ 57 /1 r}7tUnNitzz- TOTAL VALUATION: + r - r RECEIttEI�BTC '-� � By my signature below,I certify to each of the following: I am the prope er ora orized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. !A03 v escri .of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building co c ze repre atives of Cupertino to enter the above-identified prop e for inspection purposes. Signature of Applicant/Agent: �' _��- Date: SUPPLEMENTAL INFORMATION REQUIRED A,fEPMiscApp_2011.doc revised 03/16/11