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11060210 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6790 JOHN DR CONTRACTOR:SCOTT FITIUJHOFF PERMIT NO: 11060210 OWNER'S NAME: SCOTT FITIUJHOFF 6790 JOHN DR DATE ISSUED:06/27/2011 OWNER'S PHONE: 4087477503 CUPERTINO, CA 95014 PHONE NO: LI LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG� ELECT I— PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION: INS'I'A1,l.PROPERTY LINE:CLEAN OUT 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. 1 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:$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:36923001.00 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 FM LAST CALLED INSPE IO indemnify and keep harmless the City of Cupertino against liabilities,judgments, / JJ //1 costs,and expenses which may accrue against said City in consequence of the Issued by: Gly 6- Date:7r 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. 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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: hereby affirm that 1 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) 1,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,Se �20 _533,a d 25534. Section 3700 of the Labor Code,for the performance of the work for which this 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,1 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, ,sts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. anting of this permit.Additionally,the applicant understands and will comply with all non-point source reg=Date— o Municipal Code,Section Licensed Professional 9.18. Signature W) i/ CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN 36923001 . 00 DATE ISSUED. . . . . . . : 06/27/2011 RECEIPT # . . . . . . . . . : BS000013896 REFERENCE ID # . . . : 11060210 SITE ADDRESS . . . . . : 6790 JOHN DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER SCOTT FITIUJHOFF ADDRESS 6790 JOHN DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : S . FITINGHOFF CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY SCOTT FITIUJHOFF ADDRESS 6790 JOHN DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3 , 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 3 , 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRSEWER UNITS 1 . 00 21 . 00 0 . 00 21 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 106 . 50 0 . 00 106 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 106 . 50 chk --------------- TOTAL RECEIPT 106 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 6790 John Dr. DATE: 06/27/2011 REVIEWED BY: jsg APN: BP#: "VALUATION: "PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK Install property line cleanout SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $21 TOTALS: $21.00 77 Plumb.Plan Check 0.01 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.00 . NOTE. Thesefees are based on the prelindnary information available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (Pee.Resolution 09-05/ f;f'. '1.-1( FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Stroniz Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 ' ()(-P SUBTOTALS: $105.00 $0.00 TOTAL FEE: --$tOF.W Revised: 04/29/2011 GENERAL PERMIT APPLICATION MEP Lo COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• building(alcupertino.org MIS C CiJPERTINO I ! UP 0-Z I C:1 QPLUMBING [:1 MECHANICAL ELECTRICAL MISCELLANEOUS � PROJECT ADDRESS 6H. ,J v f APN# / L Lill— OWNER NAME S(c (/ }�' /�.7 ! PHONEE�f7 EMAIL Sri/l✓1��?'�7 e��}/J�I '/JC �h STREET ADDRESS v G CITY, STATE,ZIP /� (' J �S Q/ FAX `� A CONTACT NAME }{ 5 f I 1`�`N /l 1 PHONE STREET ADDRESS CITY,STATE, ZIP FAX A,/ 4 ❑OWNER L'1 0W,R-BUIIAER 1-1OWNERAGENT El CONTRACTOR CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER 11 DEVELOPER ❑ TENANT CONTRACTOR NAME n r L9 �r J I� JLICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME /Tea rte, 71,1( p E-MAIL FAX STREETADDRESS ZS�� aki n ?Y / CITY,STATE,ZIPi6b5 /`� G�c P S+� PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER t(Vv G 7 BUS.LIC`#/Y COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES 7FLOOD OJECT IN ❑YES IS THE BLDG AN ❑ YFyS BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA WO ZONE `n+��,0 EICHLER HOME? �O DESCRIPTION OF WORK f Il �r� �12 )'v -t r�✓► LA w 4 (��t TOTAL VALUATION: 02 D RECEIVED BY: By my signature below,I certify to each of the followin operty owner or authorized agent to act on the property owner's behalf. I have read this application and the information I hav ided is ect. have readyescription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin o ildin co orizeentatives of Cupertino to enter the ab property for inspection pu{poses. Signature of Applicant/Agent: Date: 6 SUPPLEMENTAL INFORMATION REQUIRED �{ OFFICE USE ONLY lJ OVER-THE-COUNTER ❑ EXPRESS Y U ❑ STANDARD U F 1EPMiscApp_2011.doc revised 06/21/11