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11040097 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22601 VOSS AVE CONTRACTOR:DALLAS CARLOCK PERMIT NO: 11040097 PLUMBING SERVICE OWNER'S NAME: CITY OF CUPERTINO 16721 MADRONE AVE DATE ISSUED:04/14/2011 ER'S PHONE: 4087773212 LOS GATOS,CA 95030 PHONE NO:(408)354-5413 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL COMMERCIAL r Contractor Date JOB DESCRIPTION:REPLACE BAD SUPPLY WATER LINE PIPES RUNNING I hereby affirm that I am licensed under the provisions of Chapter 9 FROM (commencing with Section 7000)of Division 3 of the Business&Professions METER TO BUILDING(APPRX 80')SCHEDULE 80 Code and that my license is in full force and effect. PVC.INCLUDE PARALLEL BACK FLOW DEVICES AND BRASS 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. 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 Sq.Ft Floor Area: Valuation:$7000 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:34215038.00 Occupancy Type: 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. -- Signature Date Issued by: ! Date: OWNER-BUILDER DECLARATION tiereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to ,, yuctthe project(Sec.7044,Business&Professions Code). 0711 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the 1 have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. 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. Ow thorized agent- forthwith gent j j r Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is g I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relatin to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name in,'^mnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the Lender's Address gi....,mg of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. �� / I understand my plans shall be used as public records. Signature f�� Date - Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22601 Voss Ave. DATE: 04/14/2011 REVIEWED BY: GS APN: BP#: `VALUATION: $7,000 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION 1 CPWS USE: Commercial Building PERMIT TYPE: WORK Replace water supply line from meter to building 80' schedule 80 with new ball valve. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Service 1 BPWSVCS 1 # $21 TOTALS: $21.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 �rs $42.00 E3-L- NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resohrtion 09-05I E�.' ill/101 FEE QTY/FEE MISC ITEMS ar 1 s z PME Plan Check: $0.00 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? O Yes (F) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 A Strom Motion Fee: IBSEISMICO $1.47 Select an Administrative Item Bld�T Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $107.47 $0.00 TOTAL FEE: $107.47 Revised: 03/01/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Lo (408)777-3228• FAX(408)777-3333•building(Mcupertino.org MISC CUPERTINO PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS , . .. �_-C/ �fI l (S 4 U Q APN# OWNER NAME PHONE / E-MAIL 772-3 STREET ADDRESS CITY, STATE,ZIP / / ?S Ci/ FAX 7 7_ 9') CONTACT NAME .,- E-MAIL MAIL C_u U i s ?� �2 X72 - 6777 n CITY,STATE,ZIP FAX C STREET ADDRE _3• 1 /it•� ��+eC�.e.�1 .^ /r✓ L'a /SCS i 777 - 3 / ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT 11 ENGINEER l3 DEVELOPER ❑TENANT CONTRACTOR NAME r1 1 ; /` /�< /C LICENSE NUMBER /C-7 LICENSE TYPE BUS.LIC# COMPANY NAMEj E-MAIL - FAX o 6 U STREET ADDRESS CITY,STATE,ZIP,/.. PHONE 3:-y- ARCHITECT/ENGINEER NAME f. LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ISE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROTECT IN STRUCTURE: 1� Commercial URBAN INTERFACE AREA ❑ Yes A_NO FLOOD ZONE ❑ Yes 4-'No DESCRIPTION OF WORK r r b C. r/(�i wn �c� `� SC- 9/21A � � a�-�c -�- cv: ,, ..,c.� l� i2��:1' V/-► / 'CEJ" fqf TOTAL VALUATION: RECETY,ED,BY r., L c�: - 71 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 construction. I authorize repres_wwfiives of Cupertino to enter the above-identlfie prope for inspection purposes. \ ZZ Signature of Applicanr/Agent: t � J _kir�/ Date: L SUPPLEMENTAL INF TION REQUIRED -G .... .. 14tA�lt w E z, MEPMiscApp_2011.doc revised 03/16/11