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11030118 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10160 MILLER AVE CONTRACTOR:' ftjge PERMIT NO: 11030118 OWNER'S NAME: RICK KYUTOKU DATE ISSUED:03/28/2011 OWNER'S PHONE: 4082204040 PHONE NO: L LICENSED CONTRACTOR'S DECLARATION ," BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C4 Lic.# °l 051 �O '1 MECH F RESIDENTIAL COMMERCIAL Contractor 3aus I10 rPz TIL&K b Date 3 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:UTILITY ROOM-INSTALL APROXIMATELY 90FT OF GAS (commencing with Section 7000)of Division 3 of the Business&Professions PIPE UNDER GROUND&IN CRAWL SPACE,STARTING AT METER WITH 1 1/4"&ENDING AT DRYER(1 1/4)&WATER 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 for which this Sq.Ft Floor Area: Valuation:$3100 permit is issued. APPLICANT CERTIFICATION APN Number:37501002.00 Occupancy Type: 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by 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. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 mustTnr zed agent: forthwith comply with such provisions or this permit shall be deemed revoked. Dater CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is 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 relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the,City of Cupertino against liabilities,judgments, Lender's Address cq,and expenses which may accrue against said City in consequence of the ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION w....all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37501002 .00 DATE ISSUED. . . . . . . : 03/28/2011 RECEIPT #. . . . . . . . . : BS000013005 REFERENCE ID # . . . : 11030118 SITE ADDRESS . . . . . : 10160 MILLER AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : RICK KYUTOKU ADDRESS . . . . . . . . . . : 10160 MILLER AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : BAYSHORE PLUMBERS 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 3, 100. 00 1. 00 0. 00 1 .00 0.00 1BSEISMICR VALUATION 3, 100. 00 0 .50 0. 00 0 .50 0. 00 1PGASRES OUTLETS 1.00 63 . 00 0.00 63 .00 0. 00 1PPERMITFE FLAT RATE 1.00 42 . 00 0 . 00 42 .00 0. 00 1TRAVDOC FLAT RATE 1.00 42 . 00 0 . 00 42 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 148.50 0. 00 148.50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 148.50 #1958 --------------- TOTAL RECEIPT 148.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10160 miller ave DATE: 03/28/2011 REVIEWED BY: larry s APN: 37501002 BP#: "VALUATION: 1$3,100 RIPERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPGAS USE: PERMIT TYPE: WORK install 90 feet of gas pipe, starting at meter 11/4 to dryer 3/4 and water heater(3/4). SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $63 -T- TOTALS: $63.00 T7Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. 0.0 hrs $42.00 - Li NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the Dept-for addn I info. FEE ITEMS (Pee Resolution 09-051 F;f'. ' 1.-1O) 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 No $0.00 Travel Documentation Fee: 1 TRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $148.50 $0.00 TOTAL FEE: $148.50 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@cupertino.org MISC CUPERTINO ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS V PROJECT ADDRESS I n I („ O M i { e r �N# '� 01 ��o OWNER NAME (CIX ��'i\ PHOE-MAIL 4NEL STREET ADDRESS '�l O M! I I e r V STA ,QIP O FAX CONTACT NAME J 1 AN n PH NE E MA �'e k bets. STREET ADDRESS P D v [ C TE, IP FAX Cpm I` G ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR AGNTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRA R NAME ^ 4 C NUMBER LjCENS TYPE BUS.LIC# COMP NAM E-M IL FAX SVir,r uv✓tl�r Coh �us �a or i kl►nv m STREE ODRE Doxr A A e Q ^/ ^A Oy got PHONE r ARCHITECT/ENGINEER NAME 7 1VLLICCENSE NUMBER I ` BUS.LIC# ,P COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ NO FLOOD ZONE ❑ Yes ❑ NO DESCRIPTION OF WORK n f �G I G2. ski Vi -t- 11JU P"" cn TOTAL VALUATION: O O RECEIVEDBY-" 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 relatingbuildin o uction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: ZS i S PPLEME AL INFORMATION REQUIRED " " _-WW� ��..'•.�R1;ss `m ,L�uSTAxDARD Q LARGE ` � w MEPMiscApp_2011.doc revised 03/16/11