13110029 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1097 KENTWOOD AVE CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 13110029
OWNER'S NAME: SCHATZ NANCY H 7020 COMMERCE DR DATE ISSUED: 11/05/2013
OWNER'S PHONE: 4082537931 PLEASANTON,CA 94588 PHONE NO:(925)4444444
10 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class Pt-0 Lic.# ,� l-10 o REPLACE 7 SUPPLY DUCTS
Contractor S(9tkfiLJb1 (c 4l S Date ("J
1 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:$3728
Vehave and will maintain Worker's Compensation Insurance,as provided for by
ction 3700 of the Labor Code,for the performance of the work for which this APN Number:35930017.00 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 1 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 DAY OM LAST 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 Date:
granting of this permit. Additionally,the applicant understands and will comply
Issued by:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date l All roofs shall be inspected prior to any roofing material being installed.If a roof is
-7-1 installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION Date:
Signature of Applicant:
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
1,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)
HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
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
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
performance of the work for which this permit is issued.
vided for by
the Health&Safety Code,Sectipns 25505,25 33,and 25534.
1 have and will maintain Worker's Compensation Insurance,as pro
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen .v4AAE Date: �y �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.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 PERMU APPUCATION MEP
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1030a ToE�.RE.AVENUE-CUP E;E"I MO,CA 9EO14-3255
(408)7T7-3225-FAX(408)—777-3333- MIS C
CUPERTINO
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 1097 kentwood ave DATE: 11/05/2013 REVIEWED BY: Mendez
APN: BP#: `VALUATION: $3,728
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PENTAMATION
PRIMARY 1 RMAP7
USE: SFD or Duplex PERMIT TYPE: 19
WORK re lace 7 supply ducts
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Ventilation System 1BREMVENS 1 # $104
TOTALS: $104.00
Mech.Plan Check "00 $0.00 rbwr t, 1rt,m 1,ln Chc,k
Mech.Permit Fee: IMPERMIT oll'. > ""tilt F, F.l ( P<,st it t<<e
Other Mech.Insp. 0.0 hrs $47.00 Otrs-,i.r I m 17Y<<r,>_ Urfrc r/10, lily,
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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 prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS(Fee Resolution 11-053 U 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fec:
Suppl. PC Fee
T--=
PME Plan Check: $0.00
Pcrmit 1`cv.
suppl. Insp Pee
PME Unit Fee: $104.00
PME Permit Fee: $47.00
('oIISWII(ZiOt7 7'r!:V:
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes Q No $0.00
"Idvanccd I'larmintr Fees:
Travel Documentation Fee: 1TRAVDOC $47.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
131da Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $243.50 $0.00 TOTAL FEE; $243.50
Revised: 10/01/2013
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