13030047 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11128 SUTHERLAND AVE CONTRACTOR:WATER QUALITY PERMIT NO:13030047
PLUMBING
OWNER'S NAME: KOPP ROGER G AND RIENA 1860 ALMADEN RD DATE ISSUED:03/11/2013
OWNER'S PHONE:.4082557009 SAN JOSE,CA 95123 PHONE NO:(408)267-9330
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
II
License Class Lic.# S-� �CJ COPPER RE-PIPE
Contractor At MAP, 'Date �
I hereby affirm that I am licensed ilder 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.
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. Sq Flo Valuation:$8000
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 be . 5617058.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information 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 F OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Da
with all non-poin ce r- ion Cupe Municipal Code,Section
9.18.
RE-ROOFS:
Signator Date 1 All roofs shall be inspected prior to any roofing material being installed.1£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:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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)
I,as owner of the property,am exclusively:contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7.044,.Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534.4 will
I hereby,affrrm 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 Cupertin Municipal Cpdc,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' s 25505, d 24.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized age 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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
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,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit:Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION MEP
10 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINQ
19
(408)777-3228•FAX(408)777-3333•building a0 \3
cupertino.org 6; misc
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❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 13 ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPEC BUS.LIC#
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USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: �� RLCEIYEDBY:
By my signature below,I certify to each of the follow owner or Aauthtd agent toact on the ro owner's behalf. I have read this
application and the information I have provided is co t. have re d the De ption and verifyit is accurate. agree to comply with all applicable local
ordinances and state laws r tin o,buil 'ng co o I ze representa ivesrtino to enter the ov]SI-identifi property for inspection purposes.
Signature of Applicant/Age r r
Date:
SUPPLEWNTAL INPOItMATION REQUIRED ONLY,,
W' OVER-THCOUNTER
H 0 EXPRESS
w ❑ STANDARD
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Gl marox.
MEPMiscApp_201 1.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 11128 Sutherland ave DATE: 03/11/2013 REVIEWED BY: Mendez
APN: BP#: 'VALUATION: 1$8,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPRP
USE: p PERMIT TYPE:
WORK �co er re-pipe
SCOPE
_RkWEx Fx �a
_.._ _. .
Meeh. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec. Plan Check
L1eeh.Permit I ec:: Plumb.Permit Fee: IPPERMIT Elec.Permit F'ee:
[Ifi'�'&
�r;19cch.Insp. Other Plumb Insp. 0.0 hrs $45.00 01her Elce.Insp. El
lnsp.l--'cee' Plurnl�. Insp, Fee: Elec.Insp,fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Plumbing
Suppl.PC Fee: (j) Reg. 0 OT 0.0 hr's $0.00 $13.00 IPRREPIPE Re-Pipe Interior
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Feer Reg. ® OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Conso-fiction T«x:
Administrative Fee: IADMIN $42.00
Work Without Permit? ®Yes (j) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: 1TRAVDOC $45.00 Building or Structure
Strong Motion.Fee: IBSEISMICR $0.80 Select an Administrative Item•
Bldg Stds Commission Fee: IBCBSC $1.00
� rn riL ' - $146.80
$133.80 $13.00
Revised: 01/01/2013