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13050055 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10789 ALDERBROOK LN CONTRACTOR: PERMIT NO:13050055 OWNER'S NAME: SELTENREICH GEORGE JR TRUSTEE DATE ISSUED:05/07/2013 OWNER'S PHONE: 4086744993 , PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r License Class Lic.# ` " r- F " MECH RESIDENTIAL COMMERCIAL� Contractor '54V16(-- �5$� Date 4,GA-C I I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL NEW GAS LINE FOR NEW GAS STOVE (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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$300 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36921644.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EMPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may ac c a against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Add'' ally, a applicant understands and will comply with all non-point sourc ulati per the Cupertino Municipal Code,Section 9.18. Issued by: �'� "� Date:_5;:--7—( 3 Signature Date L ` ❑ OWNER-BUILDER DECLARATION a i, RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first6btaming an inspection;I agree to remove all new materials for the following two reasons: 1,as owner of the roe inspection. property,rty,or my employees with wages as their sole compensation, _. ;,•,,as r will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:._ Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF�OV ERIN iGS TO BE CL ASS"A"-OR BETTER Thcr.. .. . C, .,t. . I hereby affirm under penalty of perjury one of the following three "'"Y'" declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle.hazardous material. Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this Q permit is issued. contaminants as derine'd'by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Saf ,Sections 25505,25533,and 25534. 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,l Ow r ~gent: become subject to the Worker's Compensation provisions of the Labor Code,I must _ Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date GENERAL PERMIT APPLIPATION MER COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildlna(7a CUDertino.Ora misc CUPERTINO PLUMBING' ]MECHANICAL IFF.ILECTRICAL nMISCELLANEOUS IV PROJECT ADDRESS;' D OWNERNAME I E-MAIL&7[ 7 C? STREET ADDRESS .r'u ': t�AJ CITY,STA ZIP( J .I FAX . At CONTACT N_AIv1E;.. �) I PHONE t I E-MAIL u!„ C FAX CITY,STATE,ZIP /�,r � I OWNER ❑ OWNER-BUII.DER'`,;� ❑OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑�ARcHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME!'+'�" /" y. LICENSENUMBER t cctt LICENSE TYPE �t BUS.LIC# 8 7 y 8010 I A COMPANY NAME I;,j j (' II j i E-MAIL Vq / FAX STREET ADDRESS,.: CITY,STATE;ZIP PHONE !; i�L'5��r c.a;i��:�=, pr�tu� Qa c2 QY�,cs� Sto-32S-�5�g ARCHITECT/ENGINEEKNAME I LICENSE NUMBER I BUS.LIC# COMPANY NAME, E-MAIL FAX STREET AI'DRE.SS CITY,STATE,ZIP PHONE ,USE OF. or DUPLEX "[ 1�lofULTI-E ,Y Ij PROTECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN CI YES BUILDING' COMMERCIAL, j�i� I. •I' URBANRMRFACEAREA ❑ NO MOOD ZONE ❑NO MCHLERHOME? ❑NO - DESCRIPTION OFj WORT ao ii I By inyjsignaturc below,I certify to each o£the following: I the rty owner or authorized agent to act on the property owner's behalf. I have read this application and;Ule'infonnatioml,have provided is correct. ad the Description;of Work and verify it is accurate. I agree to comply.with all applicable local ordinances'and state laws relating to building cons ct• tho representatives of Cupertino to enter the above- enti led property for inspection purposes. Slgpatureot;Apo!!can Agent,, Date: t 1 I I j,ILTP$I�IVIE AL INFORMATION REQUIRED pill I,I I .II I I I.III I I � ,• i � j �ijl„ II��I ;•j' I � � I, I I I � I I'''. I III I, '•I' j' '.jl��i � I,,�� I MEPMiscA 1.doc revised 06121111 PP _201 I CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION Im ADDRESS: 10789 alderbrook In. I DATE: 05/07/2013 REVIEWED BY: bobs. APN: I BP#: *VALUATION: 1$300 *PERMIT TYPE: Plumbing Permit I PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION USE: SFD or Duplex I PERMIT TYPE: 1 RPGA WORK install new qas line for new qas stove. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $67 TOTALS: $67.00 °. 1 Y {T i: 'n"v �IMMMb Lfe ch. Man Check Plum . :.h$p.:.-r,+..' -- 1'Ky'rYi��.X�.::,yy,.'• r Plan Check 1 0.0 1^hrs $0.00 Elec. Plan Cheek I I I;bfc:ch. Permit Fee: I Plumb.Permit Fee: IPPERMIT Etec.Permit Fee: Other a/ech.Insp. I Other Plumb Insp. 0.0 hrs I $45.00 other Elec.Insp. Ale&Insp. Fee: Pluff1b. 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 preliminary information available and are only an estimate Contact the Dept for addn'l info. FEE ITEMS(Fee Resolution 11-053 Eff. 711112) FEE QTY/FEE I MISC ITEMS Plan Check I,*ee: Sztpp1. PC Fee n PME Plan Check: $0.00 Peranit Fee: Supj)l. Insp 17ee n PME Unit Fee: $67.00 PME Permit Fee: $45.00 Construction Tax: n Administrative Fee: JADMIN $42.00 Work Without Permit? ®Yes 0 No $0.00 Advanc:ecl Planning fees: Travel Documentation Fee: 1TRAVDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldp-Stds Commission Fee: IBCBSC $1.00 $200.50 $0.00 °` ' TOALFEE-el $200.50 Revised: 04/29/2013