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13100133CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10296 ALPINE DR CONTRACTOR: PENNINGTON PERMIT NO: 13100133 PLUMBING SERVICE OWNER'S NAME: HOLMES BAYARD S AND IDA J TRUSTEE 1261 LINCOLN AVE STE 215 DATE ISSUED: 10/21/2013 OWNER'S PHONE: 6504652429 SAN JOSE, CA 95125 PHONE NO: (408) 217 -8352 JOB DESCRIPTION: RESIDENTIAL El COMMERCIALLJ ❑ LICENSED CONTRACTOR'S DECLAARATrION_ (--22& -? C p Z J L � UNITS A & C - REPLACE 2 (E) WATER HEATERS, SAME License Class Lic. # kpff hr < LOCATIONS Contractor Oi l 1 11 Date I hereby affirm Ma 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: $2200 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32615070.00 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 9MIT 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 D ROM L 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 ed by: a e 16d 2/ /3 granting of this pe Addit nally, the applicant understands And will comply with all non -poin so ice re ations 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) 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 will maintain compliance with the C perti unicipal Code, apter 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, Sectio 5505 533, and 2 Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: 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 CUPERTINO GENERAL PERMIT APPLICATION O\ MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION O 10300 TORRE AVENUE a CUPERTINO, CA 95014 -3255 \0 misc (408) 777 -3228 • FAX (408) 777 -3333 a building ncupertino.org \ U PLUMBING LjMECHANICAI, ELECTRICAL ❑ MISCELLANEOUS PROJECT ADDRESS v ' ,4 ` Wine- `r� f a t16 APN # °j / _ O OWNER NAME 1 P M �✓�� `�(�' /ZY`p E—MAIL cro z+- -- -- /�l �.,/fJ/ CITY, ST E, 7rn FAX ell L�� '+ _ 9Y3o G CONTACT NAME , -•� PHO E�-M4AIL tnth �YC!'� 0� 21q ^(02oU `l% , art (n Yn STREET ADDR� SS �1 ,, 2`� `❑ CITY, STA �-W � ,^' C l2 v FA7G ,/� � 7-j7 �` VDEEVELOPER (TEINANT ❑ OWNER OWNER- BUIIAER ❑ OWNER AGENT ❑� B CONTRACTOR ❑ CONTRACTOR AGENT ❑1 ARCHITECT) ❑ ENGINEER ❑ CONTRACTOR NAME _ _ _ L'fJYI \ ev�nr' �JVI LICENSE NUMBER Z� 7CENSETYPE - ^ 5 6 BUS. LIC # COMPANY NAME (1 In EMAII ` n-�, ^^•... f lX FAX STREET ADDRES GO\ 9�2 t CITY, STATE, ZIP t b CA q ^ d i 50 PHO q U �' / . n , ,� (PU10 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX BUILDING: ❑ COMMERCIAL ❑ MULTI - FAMILY PROJECT IN WI DLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? - ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: REC$ By my signature below, I certify to each of the following: I am the grope wner or authorized agent to act on the openly owner' ehalf. I h read this application and the information I have provided is correct. I have read th escription of Work and verify it is accurate. I agree to m all applicable local ordinances and state laws relating to buildin tructio au orize resentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 10— '21-13 INFORMATION MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO WAN FF.F. FCTiM A TnR — RIT-FT.DING DIVISION APPLIANCE / EQUIP TYPE 10296 ALPINE DR DATE: 10/21/2013 REVIEWED BY: 1WADDRESS: APN: 32615 070 BP #: *VALUATION: 1$2,200 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex $56 PENTAMATION pRWHEATR USE: PERMIT TYPE: WORK UNITS A & C - REPLACE 2 E WATER HEATERS SAME LOCATIONS SCOPE $56.00 APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Water Heater 1 pRWHEATR 2 # $56 Perinit Fee: Suppl. Ins,() Fee PME Unit Fee: $56.00 PME Permit Fee: $47.00 Construction Tax: -77F Administrative Fee: IADMIN $44.00 Work Without Permit? 0 Yes (E) No $0.00 TOTALS: aG -- $56 00 R X/ec:h. Man Check fecL Permit 17ee: I Other Alech. Insl). Hach. Insp. Fee: NOTE: This estimate does not Plumb. Plan Check 1 0.0 1 hrs $0.00 El,,. Plan Check Plumb. Permit Fee: IPPERMIT Elec. Permit I,ee: Other Plumb Insp. 0.0 �rs$47.00 Other Glec, Insp. Li Plumb. btsp. Fee: Glee. Insp. tire: s due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer District, School District eta These ees are based on the nrelimina information available and are on1v an estimate. Contact the Dept or aaan't info, FEE ITEMS (Fee Resolution 11 -053 E . 7111132 FEE QTY/FEE MISC ITEMS Plan Check Fact: SuFI11. PC:' Fee PME Plan Check: $0.00 Perinit Fee: Suppl. Ins,() Fee PME Unit Fee: $56.00 PME Permit Fee: $47.00 Construction Tax: -77F Administrative Fee: IADMIN $44.00 Work Without Permit? 0 Yes (E) No $0.00 ,lclvcane -ed 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 - $195.50 0.00 , Or � iFE, E . $ 195.50 Revised: 10/01/2013