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13090013FIT CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR CONTRACTOR: WATER QUALITY PERMIT NO: 13090013 PLUMBING OWNER'S NAME: THE FORUM RANCHO SAN ANTONIO 1860 ALMADEN RD DATE ISSUED: 09/04/2013 OWNER'S PHONE: 6505371523 SAN JOSE, CA 95123 PHONE NO: (408)267-9330 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIP'T'ION: RESIDENTIAL El COMMERCIALLJ License Class Lic. # a _( % **BLDG # 5**REMOVE & REPLACE 2 (E) WATER (�, HEATERS Contractor t, i ()n tis(: ISate IN MECHANICAL ROOM 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 Sq. Ft Floor Area: Valuation: $10500 performance of the work for which this permit is issued. 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 permit is issued. APN Number: 34254999.00 Occupancy Type: 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 FR CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Iss Date: t, granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per th upeftino Municipal Code, Section RE -ROOFS: 9.18. __ _... r L "t 1 Signatur Date 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 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) 1, 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. 1 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 25505,25533, the Health & Safety Code, Sections 25505, 25533_ and 255 l Section 3700 of the Labor Code, for the performance of the work for which this .... I Owner or authorized agen . ate: r 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 reed 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 CUPERTINO GENERAL-PERMIT,APPLICATION � MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION O 10300 TORRE AVENUE • CUPERTINO, CA 950143255 (� misc (408) 777-3228 • FAX (408) 777-3333 • building(a)_cupertino.org PLUMBING LIMECHANICAL ELECTRICAL LJNHSCELLANEOUS PROJECT ADDRESS APN # Z Z S� q �s OWNER NAME PHONE El STREET ADDRESS CITY, STATE, ZIP l FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUII.DER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME , LICENSE NUMBER LICENSE TYPE BUS. LIC #� p v NJIa COMPANY NAME E-MAIL FAX 6a3 r STREET ADDRESS CITY, STATE, ZIP / PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD m DUPLEX ❑ MULTI FAMILY BUILDING: COMMERCIAL PROJECT INWILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO CTIN❑ YES 7R0; OOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK�� e Ln Ail i'von� TOTAL VALUATION:/J) `�.iC_J irg,� RECEtVEil By my signature below,, II certify to each ooff the following: I am the property owner or autho ' ent ton tif prope is 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 acc agree to comply with all applicable local ordinances and state laws relating to bu y, representatives of Cupertino to enter the a-ide tified property for inspection purposes. Signature ofApplicanUAgent:u /iit(F AlTS�utho A Date: In `� �: MEPM1scApp_2011.doc revised 06/21/11 CITY OF CUPERTINO N IM -7 FFR. ESTIMATOR — BUILDING DIVISION JimADDRESS: 23500 CRISTO REY DR DATE: 09/04/2013 APN: 342 54 999 BP#: REVIEWED BY: MELISSA "VALUATION: 1$10,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Multi -Family Dwelling USE: Building is >3 Stories ® Yes ® No PENTAMATION PRWHEATR PERMIT TYPE: WORK BLDG # 5**REMOVE & REPLACE 2 E WATER HEATERS IN MECHANICAL ROOM SCOPE PME Plan Check: APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 2 # $56 TOTALS: $56.00 Xfech, Plan Check 11Plumb. Plan Check 10.0 1 hrs $0.00 Flee. Plan Check Mie& Perinil Fie: Plumb. Permit Fee: 1PPERMIT illlec. Permit Fee: 7C}thea 'Ifech. Irasyl.E17- Other Plumb Insp. 0.0 hrs $47.00 Other Elec. Ins(). rt3ech. Insp. Fee: Plumb. Inch. 7-ee: Elec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). Thesefees are based on the preliminary information available and are only an estimate. Contact the Deptfor addh7 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1112) FEE QTY/FEE MISC ITEMS Plan Check [,ee: Srrphl. F'C'.h'c>e PME Plan Check: $0.00 .l erinit./'e : Slppl. Insp I,Ge PME Unit Fee: $56.00 PME Permit Fee: $47.00 (7onslruction Tar: Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes (E) No $0.00 /idvoweed Planning; Pees: Travel Documentation Fee: ITRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $1.05 Select an Administrative Item Bldp, Stds Commission Fee: IBCBSC $1.00 $196.051 $0.00 1 R $196.05 Revised: 07/01/2013 i \v