11040134CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10239 PALO VISTA RD CONTRACTOR: - PERMIT NO: 11040134
OWNER'S NAME: TAMBE ATUL A AND ROHINI A
✓NER'S PHONE: 4083164436
J
LICENSED CONTRACTOR'S DECLARATION
License Class 11 Lic. # 0 b - -Z
Contractors (frrv9.'-, CIAATO!n Date
1 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.
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 rhich this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the a o infor ation is
correct. I agree to comply with all city and county ordinance and state laws relating
to building construction, and hereby authorize representative of this city to enter
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
granting o"
thisit. Additionally, the applicant understands and will comply
with all non- into rce regulations per the Cupertino Municipal Code, Section
9.18. (j l
Signatur Date l 1
11 OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
1 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.
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
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.
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
to building construction, and hereby authorize representatives of this city to enter
-non the above mentioned property for inspection purposes. (We) agree to save
emnify and keep harmless the City of Cupertino against liabilities, judgments,
-osts, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature
Date
,rt n ( DATE ISSUED: 04/19/2011
PHONE NO:
r F_
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECII RESIDENTIAL COMMERCIAL r
JOB DESCRIPTION: GAS LINE FOR FIREPLACE
* SEE NOTES*
Sq. Ft Floor Area: I Valuation: $120
Number: 35701072.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYM LAS CALLED INSPECT ON.
Issued by: Date:
77
RE -ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25533, and 25534.
Owner or authorized agent: Dater
CONST UCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
d " VrVX7 !\T 4"V TnL 'n rrT STC%
APPLIANCE / EQUIP TYPE
till 1 V1- �iVi Li_i iav
FEE ESTIMATOR - BUILDING DIVISION
QTY/FEE
ADDRESS: 10239 Palo Vista DATE: 04/19/2011 REVIEWED BY: gs
UNITS
APN:
BP#:
'VALUATION: $120
rPERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Du lex
p
#
PENTAMATION 1 RPGAS
USE:
PERMIT TYPE:
WORK
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Piping, Gas <=4 Outlets
1PGASRES
1
#
$63
PME Unit Fee:
$63.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$63.00
Strong Motion Fee: IBSEISMICR
Plumb. Plan Check 10.0 1 hrs $0.00
PlumMITb. Permit Fee: IPPER
Other Plumb Insp. 1 0.0 1 hrs 1 $42.00 j—,;,,,
Arnlrv. Irn ... s ti ,,/ t^nntnrt the Dent for addn'l info.
FEE ITEMS (! �e Resolution 09-051 Eff '-1. %0)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$63.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes E) No
$0.00
Travel Documentation Fee: ITRA VDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bid) Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$148.50
$0.00 TOTAL FEE:
$148.50
Revised: 01 /15/2011
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMLNT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building cDcupertino.org
MEP
misc
LUMBING LI MECHANICAL L ELECTRICAL L MISCELLANEOUS
PROJECT ADDRESS 1 O 4�y APN #?55:1 (D
( �\
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1711 v
OWNER NAME T -U L_ -T-� 13 PHONE Li 0 8 316 4 y� E-MAIL � Q be-@
STREET ADDRESS ! O 2 / / 3 /4 t o l 111,17-A4.c GvF� 1tV A10 C6 CI S p l LSI ITY, STATE, ZIP FAx
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 NU B R LICENSE TYPE BUS. LIC #
COMPANY NAME J J E-MAILa� FAX
G C�
STREET ADDRESS qt� CITY, STATE, ZIP
ARCHITECT GINEER NAME LICENSE NUMBER J p BUS. LIC #
COMPANY NAME FAX
STREET ADDRESS CITY, STATE, ZIP NE
USE OF SED or Duplex ❑ Multi -Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes No FLOOD ZONE ❑ Yes No
DESCRIPTION OF WORK1 9 /-AC I '� A ' Q' CLCe
ITOTAL VALUATION: / (, �Gr k RECEIVED BY_ I
112'r L.,&�t (-"A% L- I ^ (_ _-1
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 co . 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 b c n. I ze presentatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Ag, nt Date:
LEMENTAL INFO D
MEPMiscApp_2011.doc revised 03/16/11