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14010115 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7643 SHADOWHILL IN CONTRACTOR:BERINGER PERMIT NO:14010115 CONSTRUCTION OWNER'S NAME: SAN JOSE,CA 95150 PHONE NO:(408)835-5883 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL (� q (N)DESIGNATED GAS LINE TO FIREPLACE FOR INSERT Lice se Classy�1 "� J Lic.# Contractor. V" ) Date r! I hereby affirm that I am licensed under the provisions of Chap er 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:$600 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:36225013.00 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 DAYS FR 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 I Date: AV- with all non-point source regul tion per the _upertino Municipal Code,Se 918. 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 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 25505 25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent: " 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 918. Signature Date GENERAL PERMIT APPLICATION �` MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION \o 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 (408) 777-3228•FAX(408)777-3333•buildingQcupertino.org MISC cuf��trla PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN# / 2 OWNER NAME ' B MAIL STREET ADDRESS ,l- CITY, STATE,ZIP I FAX CONTACT NAME ( , PHO J'� v EMAIL 7' C 1 QC c STREET ADDRESS l-CITY,STATE,ZIP FAX T V ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME1{� 1 \ �` LIE 7 LICEM TYPE BUS.LIC# COMPANY NAME \f 1 t1..d JJ LAD� E-MAIL FAX STREET ADDRESS J �Z ' CITY,STATE,ZIP PHONTTE ARCHITECT/ENGINEER NAME J LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET.ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MUL71-FAMILY PROJECT INWIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK4z L jV (� l/7 n n � lima TOTAL VALUATION: l` EIVED By my signature below,I certify to each of the foll hg: I e property owner or authorized agent to act on ve property own e' be £ I have read this application and the information I have pro 'ded is o e t. I read the Description of Work and verify it is accurate I agree ly with 1 applicable local ordinances and state laws relating to b ' i co orize representatives of Cupertino to enter the ab entifiedction purposes. Signature ofApplicant/Agent: SUPPLEMENTAL INFORMATION REQUIRED � usy ; ME 0. Rd H)<C4ITiaTRR '- �XI? SSlea . j STANDARD - WN 5ffl-j MO. MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 7643 SHADOWHILL LN DATE: 01/21/2014 REVIEWED BY: MELISSA . APN: 362.26 013 :BP#: "VALUATION: $600 xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPGAS USE: P PERMIT TYPE: WORK N DESIGNATED GAS1 LINE TO FIREPLACE FOR INSERT SCOPE loa � � �` . a � ggs I, ,'tech. Elan(."heck Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan€:he(,,k Mech.Permil Fee: Plumb.Permit Fee: 1PPERAHT Elec. Permit I ee: Other•;�1ech.Insp. Other Plumb Insp. 0.0 hrs $47.00 Outer Elec.Insp. D:Iech.Insp:lee: Plumb. Insp. Fee: face.Insp.Fee: NOTE:This estimatedoes not inchulee fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These-fees are based on f e relimina information available and are only an estimate. Contact the De t onaddn'l info. FEE ITEMS &F e Resolution 11-053 Ef.. 7/f 1113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F 1 # Plumbing Suppl.PC Fee: .Reg. ® OT 0 0. hr's $0.00 $70.00 1PGASRES Piping,Gas<=4 Outlets PME Plan Check $0.00 Permit Fee: $0.00 Suppl. Insp.Fee-0 Reg. ,Q OT0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee* $47.00 .T-T Construction Tax: Administrative Fee: ]ADMIN $44.00 Work Without Permit? ®Yes Q No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential 0 Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 EEtx« 209.50 a +x 3 v $139.50 $70.00 ,` ,M ..34 Tom., fi $ Revised: 01/15/2014