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13050168
CITY OF.CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1146 DERBYSHIRE,DR CONTRACTOR:PROS PLUMBING& PERMIT NO:13050168 ROOTER OWNER'S NAME: SHU-CHEN HSU/RU-PING LIN 117 BERNAL RD STE 70-205 DATE ISSUED:05/22/2013 OWNER'S PHONE: 4083907384 SAN JOSE,CA 95119. PHONE NO:(877)544-7767 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class = Lica.# S REPLACE(E)WATER HEATER,SAME LOCATION r Contractor � / Date 0 I hereby affirm that I am licensed under the provisions of hapter 9 (commencing with Section 7000)ofDivision3.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.Ft Floor Area: Valuation:$1400 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 APN Number:36221025.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that.1 have read this application and state:that the:above information is 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 authofize representatives of this city to enter upon the abovementioned property for inspection purposes. (We)agree to save :180DAYS F T C ED INSPECTION.indemnify and ke .harmlessthe City of Cupertino against liabilities,judgments, costs and expen e ;which may accre against said City in consequence of thegranting of this a it: Additionally,the applicant understands and will comply sv: with all non-p int ource 2 ations,per the Cupertino Municipal Code,Section 9.18. ,; RE-ROOFS: Signature Date C 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. ❑ OWNER-BUILDER DECLARATION 11 1 Signature of Applicant: Date: I hereby'affirm thatli 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 isnot 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,7044,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. I will. I hereby affirm 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,Section2553 )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 us uipment or devices which.emit hazardous Compensation;as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by th y Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with th Cpertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect' ns 5505, 33,and 25534. Section 3700 of the Labo}Code,ifor the performance of the work for which this permit:is issued. Owner or authorized agent: Date: 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 Crpensation laws o1j California It 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 wath,such(provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097;Civ C:) Lender's Name 'I`I !a,�PPLICANT!CERTIFICATION Lender's Address I certify that I haye:read this application and state thatthe;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,#or inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of 6apertino 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 h all(non point source re�iilat ons per the Cupertino Municipal Code,Section Licensed Professional iS �Ji II ll(IISII rI ', I DateSignaure . I II I I,I i� I1I ISI : GENERAL PERMIT APPLICATION ,� MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION L , o 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 /�U CUPERTINO (408)777-3228•FAX(408)777-3333•buildincl()cupertino.org 7 misc UrPLUMBINGA MECHANICAL [—]ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS//y//f APN# -346 2 2- OWNERNAME RV .. ! PHONE E-MAIL STREET ADDRESS CITY,STATE, FAX CONTACT NAME PHO (/?,3?0 /7 E-MAIL oa STREET ADDRESS CITY,STATE, ZIP�j. Pr /� J � � / FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER A TENANT CONTRACTOR NAMEc LICENSE E LICENSE�'YP� BUS.LIC# f L ss COMPANY NAME © E-MAIL F STREET ADDRESS/� erV( �{e 76 CITY,STATEAP e ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERC URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK qj TOTAL VALUATION: D G RECE By my signature below,I certifyitochkfthe follow" g: I am the property owner or authorized agent to acton th pery owner' b If. I have read this application and the information d is ect. I have read the Description of Work and verify it is accurate. I agree to ply with all applicable local ordinances and state laws relatinon. I authorize representatives of Cupertino to enter the above-id tified 7roperty for inspection purposes. Signature of Applicant/Agent: Date: l AIJ�KEMENTAL INFORMATION REQUIRED OFFICE USE ONLY W ?rPOVER-THE-COUNTER ❑ EXPRESS U U x ❑ STANDARD zUz a ❑ LARGE a ❑ MAJOR MEPMiscApp_2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS:'1146 DERBYSHIRE DR DATE: 05/22/2013 REVIEWED BY: MELISSA APN: 362 21-025 BP#: *VALUATION: 1$1,400 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION PRWHEATR USE:. SFD or Duplex PERMIT TYPE: WORK REPLACE E WATER HEATER SAME LOCATION SCOPE: APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1 PRWHEATR 1 # $27 $27.00 TOTALS: MIN �1 ch I4la�t,�:hcck 'i Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check'' j ifcacli,l'cttr�if Fce: Plumb.Permit Fee: iPPERMIT Elec.Per .F: ee: flzhu dlcc}h'Ir�spi'! i. Other Plumb Insp. 0.0 hrs $45.00 niherElec.Insp. &tech 1nsp.'.Fee: 1'Iunib. Insp.Fee: Elec.Insp.lee: NOTE:This estimate'',does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District etc). These ees are based on the relimina information available and are only an estimate Contact the Dept for addn'l info. FEE ITEMSi(Fee 12esolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS Plein Cl eCls F ee Sitpl. PC I Ge: PME Plan Check: $0.00 Perinil.Fee: i S,ulvi. Insr)Eee PME Unit Fee: $27.00 I?ME Pexmit Fee; $45.00 Cflnslritction �cr�. ' �, AdmmiStrativ�Fee:, IADMIN $42.00 Work Without Penn it7 0 Yes (j) No $0.00 -77 �rll.ati�red Plci�ti2ing�{els Travel Dooumientatton'Fee:, 1TRAVDoc $45.00 i tran Motzori':F ee j ,i,I;ih i 113SEISMICR $0.50 Select an Administrative Item- Bid StdsomssionFee I 1BCBSc $1.00 $160.50 $0.00 $160,50 �` Revised: 04/29/2013