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13080002 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10140 ORANGE AVE CONTRACTOR:TBS CONSTRUCTION PERMIT NO:13080002 INC OWNER'S NAME: GEORGE DATUASHVILI 3283 DE LA CRUZ BLVD STE A DATE ISSUED:08/01/2013 OWNER'S PHONE: 4082555312 SANTA CLARA,CA 95054 PHONE NO:(408)824-8888 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION; RESIDENTIAL D COMMERCIAL E] q� License ClassLic.# at �)REPLACE WATER HEATER&FURNACE IN THE SAME � b"�� LOCATIONS(GARAGE AREA) Contractor��s C'AhS�1 f�tAC�:6�. Date �'+(.�0(;� 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4000 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:35717102.00 Occupancy Type: 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 ALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City inconsequence of the / granting of this permit. Additionally,the applicant understands and will comply d Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature \C= Date %-k-PAI 3 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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 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 Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. 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 Compensation laws of 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 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 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•building(aDcupertino.org 1 misc LUMBING CIIANICAL [—]ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN# �� I _ f O OWNERNAME PHONE E-MAIL STREET ADDRESS AA CITY,STATE,ZIP FAX CONTACT NAMEv PHONE _ Z E-MAIL STREET ADDRESS P CITY,STATE,ZIP FAX OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR WCONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRA OR NAM LICEN E E LICENSE TYPE 13, BUS.LIC# COMPANY NAMEh r ` EMAIL FAX %\e e O ^� co r c�+t7 hS• STREET ADDRESS CITY,STATE,ZIP PHONE o n 4.8 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# G COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD uDUPLEX ❑ MULTI-FAMILY PROJECT IN WH.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE NO EICHLER HOME? )21 NO DESCRIPTION OF WORK 0. O A^e- W OLALx �x ` 0 OY-'� TOTAL VALUATION: yGlfO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prope wner'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 building construction. �I/authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: ` � Dater. SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY W OVER-THE-COUNTER EXPRESS El U STANDARD v ❑ LARGE w ❑ MAJOR MEPMiscApp_201 1.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10140 ORANGE AVE DATE: 08/01/2013 REVIEWED BY: MELISSA APN: 357 17 102 1 BP#: *VALUATION: $4,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY PENTAMATION FURN/AC USE: SFD or Duplex PERMIT TYPE: i WORK REPLACE E WATER HEATER& FURNACE IN THE SAME LOCATIONS GARAGE AREA SCOPE Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Check 0.0 hrs $0.00 Elec.plan Check Mech.Permit Fee: IMPERMIT Plumb.Permit Fee: IPPERMIT Etec. Permit Fee: Other Mech.Insp. E, hrs $47.00 Other Plumb Insp. 0.0 hrs $47.00 Oihcr Elec.Insp. Li .ldech.Insp.Fee: Plumb. hasp.Fee: Elea,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 addn7 info. FEE ITEMS(Fee Resolution 11-053 E . 7ff 11112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Mechanical Suppl.PC Fee: 0 Reg. O OT 1 .0.0 1 hrs $0.00 $139.00 IMFR=<100 Furnace,Forced-Air PME Plan Check: $0.00 1 # Plumbing Permit Fee: $0.00 $28.00 1PRWHEATR Water Heater Suppl.Insp.FeeQ Reg. OOT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $94.00 Construction Tax: Administrative Feer IADMIN $44.00 Work Without Permit? O Yes (E) No $0.00 O Advanced Planning Fee: $0.00 Select a Non-Residential O Building or Structure O Travel Documentation Fee: 1TRAVDOC $47.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg_Stds Commission Fee: 1BCBSC $1.00 $186.50 $167.00 = $353.50 11 Revised: 07/01/2013 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR'LLST JOB ADDRESS: tptq 0 orqk"e PERMIT#, l O $MA00 Z OWNER'S NAME: PHONE# ' 0$;' ZST_ 5" l -7, GENERAL CONTRACTOR: s -0,\ham BUSINESS:LICENSE# - ADDRESS: CITY/ZIPCODE: etrcc+� Pt *Our municipal code requires all businesses working in the.city to have a City oCupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE- UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED:A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME j' BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing ^� Heating Insulation Landscaping Lathing j Masonry Painting/Wallpaper Paving 711 Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile z� Owner/Contractor Signature Date r _a:_ -