11040004 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20187 LAS ONDAS WAY CONTRACTORrTnr T-^- IF PERMIT NO: 11040004
OWNER'S NAME: STEVEN RANDLE P!FK�I� I l I(1 5 DATE ISSUED:04/01/2011
NNER'S PHONE: 4082559172 u PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTIO RESIDENTIAL El COMMERCIAL11
License Class G Lic.# (O (y REMOVE AND REPLACE WATER HEATER IN GARAGE
Contractor W k LA,►&1S Date Lf /
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:$1300
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:36931005.00 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 ZAST CALLED INSPECTI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, /
costs,and expenses which may accrue against said City in consequence of the /
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature— Date All roofs shall be inspected pn 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
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)
I,as owner of the property,am exclusively contracting with licensed 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 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Y /
Owner or authorized agent:_ 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
upon the above mentioned property for inspection purposes.(We)agree to save
':emnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
,,sts,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
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36931005 . 00
DATE ISSUED. . . . . . . : 04/01/2011
RECEIPT # . . . . . . . . . BS000013070
REFERENCE ID # . . . : 11040004
SITE ADDRESS . . . . . : 20187 LAS ONDAS WAY
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER STEVEN RANDLE
ADDRESS 20187 LAS ONDAS WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM ALFRED WILLIAMS
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 1, 300 .00 1. 00 0 . 00 1 . 00 0. 00
1BSEISMICR VALUATION 1, 300 . 00 0 . 50 0 .00 0 .50 0 .00
1BUSLIC FLAT RATE 1.00 115 . 00 0 . 00 115 . 00 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 225 . 50 0 .00 225 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 225.50 VISA
---------------
TOTAL RECEIPT 225.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ------------------------
518 WATER HEATER
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U PERTI NO Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 2-131 $7 Ump1 r PERMIT#
OWNER'S NAME: ' ve(-t PHONE# 7 S
GENERAL CONTRACTOR: PC7-1 "V w(wlAt-tJ PQ-046SINESS LICENSE#
ADDRESS: 10 ?6 % Z` A+,j7J- G CITY/ZIPCODE: 7k A-
*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 HAVE 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
FTile
Owner/Contractor Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20187 las ondas way DATE: 04/01/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $1,300
;'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: p PERMIT TYPE:
WORK replace water heater at gara a local
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 hr s $42.00
NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (Fee Resolution 09-05I I ff. 7/1,`10) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $25.00
PME Permit Fee: $42.00
Work Without Permit? Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $110.50 $0.00 TOTAL FEE: 1 $110.50
Revised: 01/15/2011
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
La (408)777-3228• FAX(408)777-3333 •building at?.cupertino.org
misc
CUPERTINO
PLUMBING MECHANICAL LECTRICAL ❑MISCELLANEOUS 116
PROJECT ADDRESS � _ /Z 'j /;Li y? / APN# 43! (/I ()
OWNER NAME C��T Cy �
C v �'l PHI I Z E-MAIL
STREET ADDRESS,-i CITY,STA r ZW8 � ,f, FAX
CONTACT NAME PHONE (C-0� E-MAII
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBERC LICENSE TYPE BUS.LIC#
COMPANY NAME E-MA FAX
kmJ ��NI C5 r�(n w � 01 W f I a w s z t, @ (k)A4 K�t r , - ry
STREET ADDRESS 1 [ (�C&-T,S T, CITY-STATE,, / �� PHQNE
ARC=CT/ENGINEER NAME LICENSE NUMBER ( VY BUS.LIC# O
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF EKSFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA Cl Yes ❑ No FLOOD ZONE ❑ Yes ❑ No
DESCRIPTION OF WORK
TOTAL VALUATION: -) `r.(,, RECEIVEIIBY z
.,a
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I 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 constructionauthorize representatives of Cupertino to enter the above-#mjfied property for inspection purposes.
Signature of Applicant/Agent: `' Date:
SUPPLEMENTAL INFORMATION REQUIRED
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MEPMiscApp_2011.doc revised 03/16/11