12110017 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20078 JOHN DR CONTRACTOR::,. r,.4F 1.rzjFvA (r 2 PERMITNO: 12110017
OWNF.R'SNANIF.: PFUND KONRAD AND HILDEGARD TRUSTEE A1C k -V���� 5 DATE ISSUED: II/052012
OWNER'S I'DONE: 9253229862 J aibl tJ LT' rIIONE.NO:
❑ LICENSED CON'IR,xCI'OR'S DECLARATION BUILDING PERNIITINFO: BLDG r ELECT I- PLUMB r
License Class e —3(e B Lic.H (-i z T Co/ I- ❑ r
N1FCF1 � RESIDENTL�L COMMERCIAL
Contractor�4-Z`Ji7'C(L 1�2 W..Se1i Date t I(/ (Z
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RUN NEW 3/4"GAS LINE FROM MCfER TO NEW GAS
(commencing with Section 7000)of Division 3 of the Business& Professions COOK
Code and that my license is in full force and effect. TOP
1 hereby affirm under penalty of perjury one of the following two declarations:
1 have unit will maintain a cenificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perlbrmance 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 performancea work for which this
permit is issued. G P i Sq.Ft Floor Area: Valrmtion:$900
APPLICANT C1iR'ru?1CA•1'10N
I cenify that I have read this application and state that the above information is APN Number:36934026.00 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 ofCupertino against liabilities,judgments, PERMIT EXPIRES IF WORD IS NOT STARTED
granting
of
fthisper whichtAddaynccmeagapplist aid undersandsandIsilofthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Sectiott 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature 7 D.'9� 6 f fl'A.;, Date IA-le Issued bv: Dale: /- S 12-
0
Z❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt front 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 am inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sce.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
herehp affirm under penahN of perjury one of the following three ALL,ROOF COVERINGS TO BE CLASS"A"OR IIE ITIiR
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I IAZARDOUS 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
I have and will maintain Worker's Compensation Insurance,as provided for by California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupenfno Municipal Cade.Chapter 9.12 and the I Iealth&
Safety Code,Section_553_(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
1 certify that in the performance of the work for which this permit is issued,I shall contaminants as defined Iw the Bay Aren Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's mainwin compliance with the Cupertino Municipal Code.Chapter 9.12 and[lie
Compensation laws ofCalifomia. If,alter making this certificate of exemption,I Ilealth&Safety Code,Sections 25511.5,25533,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 Oww tar "rpa orizcd ngcm:
*1� tM�^'+�
A PPLI CANT CF.RT'I FICATION CONS'IRUCITO,N'LENDING AGENCY
I certify that I have read this application and state that the above inlbrmation is
correct.I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCI11TECI"S DECLARATION
9.18.
1 understand my plans shall be used ms public records.
Signature Date
Licensed Professional
c> F-eL) -h>,-� "2 ( 16U ) -7
GENERAL PERMIT APPLICATION M E f
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ,
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 R w A .
GUPERTINO (408) 777-3228 • FAX(408)777-3333 • building Qc cuoeriino.ora '\e/I va
LUM3ING ❑MECFL42-TICAL ❑ELECTRICALL ❑11USCE.LANEOUS
PRO=ADDRESS I '-FNz /7 69 U ZG/
�x
OW'NLRAMS PONEo2s .LI E-MAIL S• ��N /51.5/D u-3 v>^ o -�-.�.nJ / '• 3 Zz -�8G
SIREETADDRESS !'j> Fia uk(--- ,I ED, I C Y. STATE,ZT I FAX
CONTACT NAME �� y PHONE E-MA'L
STR£cTADDRESS I CITY,STATE, ZIP FAX
❑ OWNa- ❑ OWNER-BUVDER ❑ OWNER AGrT'i CDN,""ti ACTOR ❑COXTRACTDR A ❑ ARCr�,� ❑ZNG'l•:]Ek ❑ DE ELOPM- ❑ :7UNT
CONTRACTOR NAME llC'VSE NUM97t LCrT'SE TY7E BUS.LIC'.
X /� q i�3•(o 755/6 ( G-3b
/ 'Y?J N L (S w��C..� Y C-tl-.iv�V l`�}� :-MAIL FAX
STF=ADDRESS Ci TY.STATE,ZIP I PHONE
ARC.YRECI—GAI--:R NAME LICENSE NUNSER I BUS.LIC:
COMPANY NAME' I E-NASI- FAX
STR=ADDRESS I CITY.STATE,ZIP PHONE
USE: OF ❑SM v DUPL.J( ❑ MULTLFAMRY PROJECT N W BDLAND ❑ YE PROJECT IN ❑Y3 is T -BLDC AN ❑ YE
BUILDING: ❑cowCERCLSI. I URBAN INTERFACE AREA ❑ NO I FLOOD LANE ❑NO EICHL9t HOM ❑ NO
DFSCA.PIION OF WORK
( �J-3 { Ct^,xrZ4- u- /V!q•v CJro 1C moi!1,
X
x10TALVALL'ATION: ��, I RECE D9Y:
By my signamre below,I c,--dy to each of:he bllowing: I am be property owner or enc`torimd agent to ac;on the prep O'Der's behalf. I have read;his
zppliczdon and the information I have provided is correct I have read Lhe Description of Work and veri„it is accIn-Z'e. I agrr_,)o comply witli all applicable local
o:din==and state laws relaun buii})Osng construction. I author,'ze represenadves of CDpenino to enter the above idcnti/F�"ed pmpe.—,j`or inspection pulposes.
Signature of ApDlicant/Agene N �C-�J�--YC/ Date: I�s/ ?/
SUPPLENENTAL INFORMATION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
❑ EXPRESS
V
"� ❑ STANDARD
U
L ❑ URGE
❑ MAJOR
lC,p.VUcApp_2011.doc revised 06/21111
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 20078 John Dr. DATE: 11/05/2012 REVIEWED BY: RDW
\ APN: BP#: VALUATION: $900
*PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARI' PENTAMATION
USE: SFD or Duplex PERMITTYPE: 1RPGA
WORK Run new 3/4" gas line from meter to new gas cook-to
SCOPE
APPLIANCE,/EQUIP TYPE FEE ID. QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1PGASRES 1 # $67
TOTALS: $67.00
Alech. Plan Check Plumb. Plan Check 0.0 hr5 $0.00 Elee. Plan Check
Mec/). Permit Fee: Plumb. Permit Fee: IPPERMIT E1ec. Permit Fee:
Other Adech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other face.Inst). EJ
Adech.brsp. Fec: Plumb. hrsp. Fee: rice.Insp. Fee:
NOTE: This estimate does not include jeev due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School
District,etc.). These eev are based on the prelitnintu3 information available and are only an estimate Contact the Dept for addn'I info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/12) FEE QTY/FEE MISC ITEMS.
Plan Check Fee: .
Srtppl. PC Fee
PME Plan Check: $0.00
Pernit Fee:
Suppl. Insp Fee
PME Unit Fee: $67.00
PME Permit Fee: $45.00
Consnvction Tax
Administrative Fee: ]ADMIN $42.00
Work Without Permit? O Yes (E) No $0.00
Advanced Planning bees:
Travel Documentation Fee: ITRAVDOC $45.00 A
Strong Motion Fee: IBSEISABCR $0.50 Select an Administrative Item
I31de Stds Commission Fce: IBCBSC $1.00
SUBTOTALS: 1 $200.50 $0.00 TOTAL FEE: 1 $200.50
Revised: 10/01/2012
m rl I f �7
ON � W �� la
` m
o a
A o o
fel O_ c�
So
o F;3
C V ^I
S r2. O m
U� I
oft �--�--
� _0
0 o c
w
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C O P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: Lro7 ,/Z. PERMIT# 2/16o( 1
OWNER'S NAME$ NV ,,,.t uS( 1Mo a4,J PHONE # S0-5'37 -/2 6
GENERAL CONTRACTOR: jL pL,J BUSINESS LICENSE #
ADDRESS: P0. -2Qrzbwavo V 9/ ITY/ZIPCODE:'
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL UBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. 1
1 am not using any subcontractors: ��
Signature Date
Please check applicable subcontractors and complete the following information:
✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring./Carpeting
Linoleum / Wood
Glass /.Glazing
Heating
Insulation
Landscaping -
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date.