13100149 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10352 PALO VISTA RD CONTRACTOR:MIKE COUNSIL PERMIT NO: 13100149
PLUMBING INC
OWNER'S NAME: ALLISON SCHWANDA 1915 O'TOOLE WAY DATE ISSUED: 10/23/2013
OWNER'S PHONE: 4088369645 SAN JOSE,CA 95131 PHONE NO:(408)2724900
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
EI
License Class CYO,_ Lic.# -S 93),,-4q REPLACE MAIN WATER LINE FROM METER TO
n PROPERTY&
Contractor i kg- N%r6A ft,,mb 0• i REPLACE OLD&IZ4STALL(N)75 GAL WATERBE TER,
I hereby affirm that I am licensed under the provisions of Chapter 9 SAME( O A N i
(commencing with Section 7000)of Division 3 of the Business&Professions
b ..v
Code and that my license is in full force and effect. �. ,,� t
Al
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
flormance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$7000
[ ave and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:35702052.00 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 180 DAYS OF RMIT 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 F A 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
granting of this permit. Additionally,the applicant understands and will comply Is Date: Z
with all non-point source regul 'ons pert Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signatur Date I.l� "�`�'`� 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
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)
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
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Airtn25534.
Management District I
performance of the work for which this permit is issued. will maintain compliance wie Cup ino Mode,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,SE' ns 2 5 25533
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: V Date:
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
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
�I
GENERAL PERMIT APPLICATION (�� MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �V
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC
CUPEitTINO (408)777-3228•FAX(408)777-3333•building(typertino.org
PLUMBING ❑MECHANICAL
ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS I I\ ` APN# 3 5-,Z_
OWNER NAME !S PHO(E E-MAIL
3'e A �ec a� YOS q(0415
STREET ADDRESS C uY, STATE ZI FAX
Sarni u e.c a \vdo 9S� �I
C E SPHONE E-MAIL
arKl
STREET ADDRESS Y,STATE ,ZIP `t � FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
rCO I•RA E ' / LICENSENUMBER (.��t� LICEN�TYPE BUS.LIC#
Cp�M 4 NAME UU E---JJMAIL !!�, FAX
STREET ADpr'S PHONE
O' I2 , C ,STATE ZIP n V1 -/S� W'6 C O o
ARCHITECT/ENGINEER NAME LICENSE NUMBER / BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
�d1S- e2 v,'C 0420
-� Q ' I (
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the projDeos
er or authorized agent to act on the property o "behalf I have read this
application and the information I have prov' d is orrect. I ha a ad ption of Work and verify it is accurate. I a e to comply with all applicable local
ordinances and state laws relating uildi on ction. I au h rize atwes of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: LJ ' L
SU PLEMENTAL ORMATION REQUIREDcEvs$otn
.,
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MEPMiscApp_201 Ldoc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10352 PALO VISTA RD DATE: 10/23/2013 REVIEWED BY: MELISSA
APN: 357 02 052 BP#: "VALUATION: 1$7,000
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Du lexH PENTAMATION 1 RPWS
USE: p PERMIT TYPE:
WORK REPLACE MAIN WATER LINE FROM METER TO PROPERTY& REPLACE OLD & INSTALL N 75
SCOPE GAL WATER HEATER, SAME LOCATION
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1BPWSVCS 1 # $24
Water Heater 1PRWHEATR 1 # $28
TOTALS: $52.00
ta1't,xrr t r,r�n Plumb.Plan Check 0.0 hrs $0.00 I-r'c- pi Cr`z�<&
Ll�ch 1' rruil f'c>c� Plumb.Permit Fee: IPPERMIT Llc Ptrrr,ir`Fac
Other Plumb Insp. 0.0 hrs $47.00 Oih�,,�t:,Cf Itisp-
Li
bkc<i° lnsh, ha�• P!unth. Fr��p. T�� I;(ec_Crisp, t`i't='
NOTE:This estimate does not include fees due to other Departments(i.e.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 De t or addn7 info.
FEE ITEMS Lee Resolution 11-053 Ef. 7/1113) FEE QTY/FEE MISC ITEMS
Ph int Chccl,. Fcc:
S1ippl. PC/'c.(,
PME Plan Check: $0.00
Peruut Fcc•
sllpp/. 111sp Fee
PME Unit Fee: $52.00
PME Permit Fee: $47.00
Consfr•uction Tax:
Administrative Fee: (ADMIN $44.00
Work Without Permit? 0 Yes (F) No $0.00
,1dti`oncc(ll'/<tnain" /`res:
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: 1BSEISMICR $0.70 Select an Administrative Item
131dyStds Commission Fee: IBCBSC $1.00
SUBTOTALS: $191.701 $0.00 TOTAL FEE: $191.70
Revised: 10/01/2013