11010048 CITY OF CUPERTINO BUILDING PERMIT
(31 II.DINc u)DRE:Ss: 20891 MC CLF.LLAN RD CONTRACTOR:SHAYNE STUBBS PERMIT NO: 11010048
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NAIL:
CUPERTINO, CA 95014-2957 PHONE NO:
❑ LICE:NSE:D CONTRACTOR'S DECLARATION f— T— r
BUILDING PERMIT INTO: BLDG ELECT PLUMB
Li�cnx•l lass Lic.b (— � �--
MECH RESIDENTIAL COMMERCIAL.
JOB DESCRIPTION ADD 539 SQ DETACHED GARAGE
I hercbv affirm that I am licensed under the provisions of Chapter 9
Icnnuncncing with Section 7000)of Division 3 of the Business& Professions
( odc 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
ontpcn aeon.as provided for by Section 3700 of the Labor Code• for the
perlormiince of the work for which this permit is issued Sq.Ft Floor Area: Valuation:$5000
h;nc and\g ill niauuain %\orkci s Compensation Insurance_as provided fir by
1rcuon,700 of the Labor(ode, for the pcifbrniance of the\s"ork for which this APN Number: 35913083.00 Occupancy Type:
pcmut is usucd
APPLICANT CERTIFICATION
ceriny th;u I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
,,greet I.igrec to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to hilddmg construction.and hereby authorize representatives ol'this city to enter
upon the ahme mentioned property for inspection purposes (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
uidenuul� and keep harmless the Cite'of Cupertino against liabilities,judgments,
and expenses which niay accrue against said City in consequence of the
-ir uiiiiw of this permit Additionally,the applicant understands and will comply Issued by: '�- Date: G �r
1111 all non-point source regulations per the Cupertino Municipal Code,Section
�� I1
RE-ROOFS:
tii nawre 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
Oy1"NER-B[ ILDER DECLARATION
Signauue of Applicant:_ _ Date:
I hereby affirm that I ant exempt from the Contractor's License Law for one of
the follm%ing two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I ;u,,v%ncr of the pi perty•or my employees with wages as their sole compensation,
Nv ill do the work_and the structure is not intended or offered for sale(Sec.7044,
liu,mcss K PlOICSSI011i Code)
t,oNNnci A the propert_N.am exclusively contracting with licensed contr c to HAZARDOUS MATERIALS DISCLOSURE
c��n,uuct the prolcct(Scc 7044 Itusiness x Prolessions Code) 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hcrebN affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.I2 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I hayc and\„ll maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
t ompunsation,as piovidcd for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay rea A' Quality Management District
perlormancc of the work for which this permit is issued. will maintain compliance with the Cup tino unicipal Code,Chapter 9.12 and
I lwn e and\s ill maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec i s25 5, 533,and 25534.
ticctioii 1700 of the Labor Code,for the performance of the work for which this
Owner or authorized
permit is iuucd
I ccrith that in the performance of the work for which this permit is issued,I shall
not cniplm ars person in any manner so as to become subject to the Workers
( ompensation laws of California. If',atter making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
hccomc 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'
lollllNllh a01111)ly x%dh 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 CERTTFICA I"ION Lender's Address
—
I ,cmly that I have read thu application and state that the above information is
coire.t I agree to comply with all city and countyordinances and state laws relating
i,,huildin-,constrrcuim.and hereby authorize representatives of this city to enter
upnn the,ihove mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
1-mmlc and keep harmless the City of-Cuperlino against liabilities, judgments,
and expenses w h may accrue against said City in consequence of the I understand my plans shall be used as public records.
of thu penmi Ad tionally,the applicant understands and will comply
h all the Cupertino Municipal Code,Section Licensed Professional_
Signatur _ Date �� z
Fil
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION:
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION 1 RPGAS
USE: SFD or Duplex PERMIT TYPE:
WORK WATER HEATER & INSTALLATION OF GAS LINE FOR GAS DRYER
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1PGASRES 1 # $63
Water Heater 1 PRWHEATR 1 # $25
TOTALS: $88.00
Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hrs $42.00
NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the De t or addn7 info,
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1,1101 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $88.00
PME Permit Fee: $42.00
Work Without Permit? 0 Yes E) No $0.00
Travel Documentation Fee: 1 TRA VDOC $42.00 i
Strong Motion Fee: IBSEISMICR $0.50 LL5 Jhrs Admin./Clerical Fee
Bldg Stds Commission Fee: 1BCBSC $1.00 $39.00 1ADMIN
SUBTOTALS: $173.50 $39.00 TOTAL FEE: $212.50
Revised: 04/29/2011