13080035 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19811 PRICE AVE CONTRACTOR:SERVICE CHAMPIONS PERMIT NO:13080035
OWNER'S NAME:
PLEASANTON,CA 94588 PHONE NO:(925)444 4444
LICENSED CONTRACTOR'S DECLA'RRATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E]
License Clasps 0" -1, ,L•ic.# �Z�`f V r REPLACE 40 GAL.WATER HEATER
Contractor Date
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:$1972
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:36905017.00 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 AYS 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 M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue,against said City inconsequence of the ,,II/
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: ,&.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
.�A( (J��Date All roofs shall be inspected prior to any r ROOFS:
Signature v(j� y 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
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 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,Secti ns 25505,2 533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent. Dater
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 PERMTT MPUCAMONMEP
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 19811 price ave DATE: 08/06/2013 REVIEWED BY: Mendez
APN: BP#: *VALUATION: 1$1,972
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEAT
USE: p PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1 PRWHEATR 1 # $28
TOTALS: ' $28.00I WE
4
Jl*ch. Plan('heck Plumb.Plan Check 0.0 hrs $0.00 El,c-Plan Check
11z;h.I'errtail Fee_ Plumb.Permit Fee: 1PPERIhIIT Iilec.Permit Tee:
Other Afech.Inst,. Other Plumb Insp. 0.0 hrs $47.00 Oilwr Elec.Insp.
Alech. h2sp. Fee: Plumb. Insp. Fee: I Elea.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addh7 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Pee
PME Plan Check: $0.00
Permit Fee:
Suppl. .Insp I%ee
PME Unit Fee: $28.00
PME Permit Fee: $47.00
Construction Tav:
Administrative Fee: IADAffN $44.00
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
IN F
L s NOW $167.50 $0.00 TQfiAIEE $167.50
Revised: 07/01/2013
For assistance or questions regarding the Energy Standards,contact the Energy Hotline at 1-800-772-3300.