13110028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10370 MIRA VISTA AVE CONTRACTOR:ALLSTAR PLUMBING PERMIT NO:13110028
OWNER'S NAME: MICHAEL P AND KAREN M ZIMMERS 326 PHELAN AVE DATE ISSUED: 11/05/2013
O—WNNEER'S PHONE: 4089961984 SAN JOSE,CA 95122 PHONE NO:(408)230-5569
I� LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
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License Class C ^�6 Lic.# � L REPLACE MAIN WATER LINE FROM METER TO HOUSE
3
Contractor P,L-L S7 R, f 1— P A V Date(W6 ( 1
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. N TA RY
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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5600
1 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:35702019.00 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 W'T"'N
S
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 S M AST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 2
costs,and expenses which may accrue against said City in consequence of the sued Date: l/A 3
granting of this permit. Additionally,the applicant understands and will corn
with all non- " t source regulations per t�upertino Municipal Code,S n
9.18. � d:�✓v.."
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. 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 Munic' 1 Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' n 5505,X9}53 a 25534. r [�
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: ` J
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.l 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
n�
GENERAL PERMIT APPLICATION O V
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION MEP
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 �l
CUPERTINO (408)777-3228-FAX(408)777-3333-build ingecupertino.org \ misc
PLUMBING ❑MECHANICAL [:1 ELECTRICAL F1 MISCELLANEOUS
PROJECT ADDRESS APN#
10-5-70 MIR i�• \(IS'CI�, Izo►� 3 O Z -b l ri
OWNERNAME L' _ PHONE 4016 4116_116 E-MAIL.
STREET ADDRESS �( CITY, STATE,ZIP FAX
0=> 6, m _TQAG� Ctk 014
CONTACT NAME l� � PHONE E-MAIL
STREET ADDRESS ft.l CITY,STATE,ZIP FAX
1(OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
--F -
CONTRACTONAME LICENSE NUMBER LICE
RNSE TYPE BUS.LIC k
PwNC'tt" Cao 3Z(oli , ' 3h o443i4
COMPANY NAME E-MAIL FAX
6 C .Gott - 5'L- 0?-S
STREET ADDRESS CITY,STATE,ZIP PHONE
31-0 T tk
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 9SFD or DUPLEX ❑ MULTI-FAMILY7RETINWILDLAND ❑ YES PROJECTIN ❑YES IS THE BLDG AN r❑yYES
BUILDING: ❑COMMERCIAL INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME" LTJ NO
DESCRIPTION OF WORK
TOTAL VALUATION: SJ (,J LJ[ CEIVED BY:
By my my signature below,1 certify to each of the following: I am the property owner or authorized agent to act on the property owner' 1 have read this
application and the information 1 have provided is correct. I have reag the Description of Work and verify it is accurate. 1 agr ply with all applicable local
ordinances and state laws relatin b Iding constn tnvn. ut e representatives of Cupertino to enter the above-d nti I property for mn salon purposes.
Signature of Applicant/Agent: Date: V ^ / ✓
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
W ❑ OVER-THE-COUNTER
a
F' ❑ EXPRESS
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5
❑ STANDARD
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❑ LARGE
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❑ MAJOR
MEPMiscApp_2011.doc revised 06/21!11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10370 MIRA VISTA RD DATE: 11/05/2013 REVIEWED BY: MELISSA
APN: 35702019 BP#: `VALUATION: $5,600
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION 1 RPWS
USE: SFD or Duplex PERMIT TYPE:
WORK REPLACE MAIN WATER LINE FROM METER TO HOUSE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1BPWSVCS 1 # $24
TOTALS: $24.00
thAl'/, /'!Cm C AI Plumb.Plan Check 0.0 hrs $0.00
lccl,. 1'e"w;l VC,- Plumb.Permit Fee: IPPERMIT Iiltc t'Ezrti;I er�
orlro, Other Plumb Insp. 0.0 hrs $47.00 oi/w-1�7o insp.
k� b,Ind. kco P'zab1"IC( Ins
1"'(-
NOTE:
(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 preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS(Fee Resolution 11-053 Eff 7/1113) FEE QTY/FEE MISC ITEMS
Plan Check
Suppl. Pt`ITE'
PME Plan Check: $0.00
Permit Fere.
Supp/. Insp Fee
PME Unit Fee: $24.00
PME Permit Fee: $47.00
("Ons1ructlon Tax-
Administrative Fee: 1ADMIN $44.00
Work Without Permit? 0 Yes E) No $0.00
,'!Eltiufrt•E�i!Planur,rw.r FE�es:
Travel Documentation Fee: ITRA VDOC $47.00
Strong Motion Fee: IBSEISMICR $0.56 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $163.56 $0.00 TOTAL FEE. $163.56
Revised: 10/01/2013