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13120122 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 949 BROOM[ROVE LN; CONTRACTOR:EVERSPRING PERMIT NO:13120122 CONSTRUCTION INC OWNER'S NAME: CHANG THOMAS T AND OLIVIA H 1131 S DE ANZA BLVD DATE ISSUED:12/16/2013 OWNER'S PHONE: 4083099019 SAN JOSE,CA 95129 PHONE NO:(408)446-8398 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL O License Class 13� Li,.# OG REMOVE AND REPLACE WATER HEATER,REPLACE SHEETROCK, �^? 1 �G / INSULATION DUE TO WATER DAMAGE Contractor��clt�� `4' "S� ate 1 I Cc C 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. 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:$20000 I 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:37539030.00 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 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 DA 'T\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 )211(911? granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: SignDate 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 Compensation,as provided for by Section 3700 of thetabor 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 Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25 05,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which thisOwner or authorized agmM. Date z t t i 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 ofCupertino against liabilities,judgments, costs,and expenses which may accrueagainst 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 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•building CUp:I`[t`�INO (aDcupertino.orpMISC ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS [/^ yy, q 1 APN# OWNERNAME PHONE STREET ADDRESS L{ CITY, STATE,ZIP, I FAX CI '[�?GoY—�iP.�J'Fr L't� CONTACT NAME `S Q_I ` ` Z Ll I¢ 'L EMAIL STREET ADDRESS CTTY,STATE,ZIP 'o F I?G-- 1- 'amu V Q ct(or� ❑ OWNEROWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRAC 0R NAME i(S�C U LICT bN 3"r-S LICEII TYPE BUS.LIC COMPANY NAMES��51 h C_G S T1�t/tC� E-MAII/Vro i FAX C vR�� C,SMa�'• /` �lG�i Fl 1 Z�/Z STREET ADDRESSp ^ , CITY,STATE,ZIP HANE osCN► �Sl 2 �O 1� (8 a ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILYPROJECT IN WII,DLAND ❑ YES T7PRJECTIN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL - URBAN INTERFACE AREA E] NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO - DESCRIPTION OF WORK G � � 1,� p �� '/ v✓�s� _ C Z.VI LA`A * xwa J� 01 01 Am ROM TOTAL VALUATION: 7�- B Nw, By my signature below,I certify to each of the following: I am the property owner or authorized agent to ac e property own hal. I have read this application and the information I have provided' .correct. I have read the Description of Work and veri Itis accurate. I agree to comply 'h all applicable local ordinances and state laws relating to building c tatives of Cupertino to en ei�le�3ti€Ie�p/ ori pection purposes. Signature of Applicant/Agent: Date: SUPPLEME TAL INFORMATION REQUIRED w ��hl`�1�dt�OFFICF�TJ3EONL�� x,w=�, IN = R aR ji V I 7 IN � •n Iwu MEPMiscApp_201126c revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 949 BROOKEGROVE LN DATE: 12/16/2013 REVIEWED BY: SYLVIA APN: J BP#: "VALUATION: 1$20,000 %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair PRIMARY PENTAMATION PRWHEATR USE: SFD or Duplex PERMIT TYPE: 14 WORK REMOVE AND REPLACE WATER HEATER REPLACE SHEETROCK INSULATION DUE TO SCOPE WATER DAMAGE OF WATER HEATER ME , r ;Leech. Plan CheckPlumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check Leech.Perwit Fee: Plumb.Permit Fee: IPPERMIT I Elec. Permit Fee: Fer Nlech.Insp. Other Plumb Insp. 0.0 hrs $47.00 Other Elec.Insp. Insp.Fee: Plumb. Insp.Fee: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These eW are based on the prelimina information available and are only an estimate. Contact the Det fiv addn7 info. FEE ITEMS(Fee Resolution 11-053 Eff. 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F 1 # Plumbing Suppl.PC Fee: ie) Reg. 0 OT 0.0 hrs $0.00 $28.00 IPRWHEATR Water Heater PME Plan Check: $0.00 Permit Fee: Hourly:Only? O Yes Q No $0.00 Suppl. Insp.Fee-0 Reg. 0 OT 0,0 1 hrs .$0.00 PMEUnit Fee: $0.00 PME Permit Fee: $47.00 Construction Tax: Administrative Fee: IADMIN $44.00 0 Work Without Permit? ®Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Travel Documentation Fee: I TRAVDOC $47.00 Building or Structure Strong Motion Fee: IBSEISMICR $2.00 2.0 hrs Inspections Bldg,Stds Commission Fee: IBCBSC $1.00 $278.00 1STINSP Inspection,Hourly $141.00 $306.00 - - ., R $4 47.00 i1ew Revised: 10/01/2013