13060162CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21381 MILFORD DR
CONTRACTOR: ALL VALLEY PLUMBING
PERMIT NO: 13060162
OWNER'S NAME: BIRKHOLZ JACK L AND.JANET A TR
3345 SELDON CT STE B
DATE ISSUED: 06/20/2013
OWNER'S PHONE: 4082577721
FREMONT, CA 94539
PHONE NO: (510)3764816
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL EI
❑ LICENSED CONTRACTOR'S DECLARATION
Lic. # "h. � �, o
REPLACE (E) WATER HEATER, LIKE FOR LIKE, SAME
License Class_
LOCATION
Contractor F'1.lkN''1 S'I'' bWA(_ Date_e-'Z Q -D
I hereby affirm that I am licensed under 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
Valuation: $750
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 32641103.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for.which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I 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 authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS F WOALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
in of the
04-3
costs, and expenses which may accrue against said City consequence
Iss Da
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
c �
Date ��
ROOFS:
All roofs shall be inspected prior to anyny roofing material being installed. If a roof is
Signature
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -B UILDER'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.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, 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 hazardo
s
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
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I
performance of the work for which this permit is issued.
the Health &Safety Code, Sections 25505, 25533, and 25534.
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
Owner or authorized agent: 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
CONSTRUCTION LENDING AGENCY
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 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
Q/7 5
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org \�
0
M NFW CONCTRI IC170N n ADY)TTInN n ALTERATION / TI I 1 REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS
APN # % i I -40
'
OWNERNAM� Aej,O
PII� 06 -d -S -2-1-7Z ( 7
E-MAII,
STREET ADDRESS
CITY, STATE, ZIP
FAX
I L
eta
CONTACT NAME 7
PHONE
E-MAIl.
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERACE NT W-rONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
—7
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
�3
&-3
COMPANY NAME
E-MAIL
L24
FAX
O - && 1-og
STREET ADDRESS
C i3
CrfY, STATE, ZIP
r' (?A 9 -f Y3i
PHONE
Sri)- ( -go
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSTR
TYPE
I # STORIES
USE TYPE OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NETAREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
[]ATTACH
I
#DWELLING UNITS:
IS A SECOND UNrr ❑YES
SECONDSTORY ❑YES
BEING ADDED? []NO,
ADDMON? ❑ NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
$Y; - TOTAL VALUATION:
PLANNING APPL # []NO PLANNING APPROVAL LETTER
EICHLERBOME? ❑ NO
By my signature below, I certify to each of the following: I am the property owner or authorized agent toKt 21owlyr6perty 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 relating to buildin chon. rize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: 0G&-'(1'3-
Ga/ D`F1r3SUPPLEMENTAL
SUPPLEMENTALINFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
VEIt THE
❑
New SFD or Multifamily dwellings: Apply for demolition permit for
_
existing building(s). Demolition permit is required prior to issuance of building
-COUNTER
BUILDING PLAN REVIEW
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
ElsrANDARD
❑ PUBIJC WORKS
form if any Hazardous Materials are being used as part of this project.
El LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 1. doc revised 06/21/11
CITY OF CUPERTINO
Kivu IV QrrTM A TnD _ III TII.11INTC 11IVICION
.
ADDRESS: 21381 MILFORD DR
DATE: 06/20/2013
REVIEWED BY: MELISSA
MISC ITEMS
APN: 326 41 103
BP#:
*VALUATION: $750
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
PENTAMATION PRWHEATR
PERMIT TYPE: A
USE:
PME Plan Check:
$0.00
Perrnit .Fee:
WORK
REPLACE E WATER HEATER LIKE FOR LIKE
Supp/, Insp Fee
SCOPE
NnTF.: This estimate doesnot include lees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Revised: 04/29/2013
.
FEE ITEMS (Fee Resolution 11-053 E 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Iy"ce:
Suppl. PC: Fee
PME Plan Check:
$0.00
Perrnit .Fee:
Supp/, Insp Fee
PME Unit Fee:
$27.00
PME Permit Fee:
$45.00
Consiruction .1"C'7:1:
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes E) No
$0.00
Revised: 04/29/2013
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