13100105CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10625 MORENGO DR
CONTRACTOR: STARBURST CONST CO
PERMIT NO: 13100105
OWNER'S NAME: ROBINSON CHRISTOPHER S AND MARY A
1207 REDCLIFF DR
DATE ISSUED: 10/15/2013
OWNER'S PHONE: 4083415109
SAN JOSE, CA 95118
PHONE NO: (408)148-1328
JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # �lT-
INSTALL (N) EXHAUST FANLIGHT COMBO IN
BATHROOM
a,
Date 1 , J
Contractor
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 infullforce and effect.
I herebyffirm under penalty of perjury one of the following two declarations:
d willmaintain a certificate of consent to self-insure for Worker's
ive
nation, as provided for by Section 3700 of the Labor Code, for the
rmance of the work for which this permit is issued.
Sq. Ft Floor Area:
Valuation: $350
ave and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 37534009.00
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
DAY ALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgment s,
c
costs, and expenses which may accrue against said City in consequence of th
sued �G /S✓ /3
granting of this permit. Additionally, the applicant understands and will c
with all non-point source regul n per the Cupertino Municipal Code, Section
9.18.
RE-ROOFS:
Signature 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)
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
as defined by the Bay Area Aid uality Management District I
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants
will maintain compliance with the Cupertino icipal Code, Chapter 9.12 and
performance of the work for which this permit is issued.:
I have and will maintain Worker's Compensation Insurance, as provided for by
,
the Health &Safety Code, Sectign5�50 � , and x5534. %
Section 3700 of the Labor Code, for the performance of the work for which this
p
U
Owner or authorized agent: � I 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
CONSTRUCTIOLE/D14G/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 i a lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
s issued
work's for which this permit is issued (Sec. 3097, Civ C.)
(S
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 \V
GUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building a.cupertino.org ! MISC
❑ PLUMBING ❑ MECHANICAL L�IELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS r-- �
Om I � � r
APN # 0 _
0 0 —7
OWNER NAMEPHONE
E-MAIL
STREET ADDRESS
CU STATE, ZIP
FAX
CONTACT NAME
E-MAIL
STREET ADDRESS
CITY, STA6, ZIP
FAX
OWNER ❑ OwNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE N�vIBE®
4
LICENS TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
j
CITY, STATE, ZIP
PHONE 4/ (lj
� YJ J S
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF or DUPLEX ❑ MULTI-FAMd
BUILDING. ❑ COMMERCIAL
PROJECT IN WI DLAND ❑ YES
URBAN INTERFACE AREA �WNO
PROJECT IN ❑ YES
FLOOD ZONE NO
IS THE BLDG AN ❑ YES
EICHLER HOME1 NO
DESCRIPTION OF WORKT,7
E�LV 4 6-F-+
TOTAL VALUATION:
By my signature below, I certify to each of the following: I am the perry owner or authorized agent to act a prope er s behalf. I have read this
application and the information I have provided is ct: hav ea the esc ' tion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin nstructio or' a re es tatives of Cupertino to enter the above -identified ope r inspection purposes.
A
Signature ofApplicanUAgent: � Date:
SUPP�,§MENTAL
TI REQUIRED
RW S37Y
nen
MEPMiscApp_2011.doc revised 06121/11
,����� CITY OF CUPERTINO
1�4""�lfl�I FFFF. F.CTIMATOR — RTTIT.DING DIVISION
APPLIANCE / EQUIP TYPE
10625,MORENGO DR DATE: 10/15/2013
REVIEWED BY: MELISSA
1AADDRESS:
APN: 375 34 009 BP#:
*VALUATION: $350
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Du
PENTAMATION 1 RMAP8
,lex
USE: P
$24
PERMIT TYPE:
WORK
INSTALL (N)EXHAUST FAN/LIGHT COMBO IN BATHROOM
Stipp 1. Insp Fee
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Ventilation Fan
1BREMVENF
1
#
$24
Perin it .Fee:
Stipp 1. Insp Fee
PME Unit Fee:
$24.00
PME Permit Fee:
$47.00
I T
Construction Taxa
-T
-
Administrative Fee: 7ADMIN
$44.00
Work Without Permit?. ® Yes Q .No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$2400
t�iz
�7:
Mech. Plan Check 10.0 1 hrs $0.00. Plumb. Plan Check
Mech. Permit Fee: IMI'ERMIT Plumb, Permit Pee:
Other Mech. Insp. 1 0.0 1 hrs 1 $47.001 Other Plumb Insp.
1tlech. Insp. Flee:
Plumb. Insp. Fee:
Elec. Plan Check
Ekec. Permit fee:
Other Glee. Insp,
Glec, Insp, Fee:
NOTE: This estimate does not include fees due to omer Departments (ie. rlanntng, ruotic rrorNs, Fire, aunliury newer uaalf Me, nciwus
mL _ _ r_ _. L,. _.,7 ,... sL,. /:.... ..0 ..An., n ni/nhlo and ono An/V an O.vdma}O_ Contact the Dent for addn7 info.
FEE ITEMS (Fee Resolution 11-053 E . 7f /f 1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC: Tee
PME Plan Check:
$0.00
Perin it .Fee:
Stipp 1. Insp Fee
PME Unit Fee:
$24.00
PME Permit Fee:
$47.00
I T
Construction Taxa
-T
-
Administrative Fee: 7ADMIN
$44.00
Work Without Permit?. ® Yes Q .No
$0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion .Fee: IBSEISMICR
$0.50
Select an. Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
=
$163.50
$0.00 ' _ E
$163.50
Revised: 10101/2013