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14010157 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10601 N BLANEY AVE CONTRACTOR:BENJAMIN FRANKLIN PERMIT NO: 14010157 PLUMBING OWNER'S NAME: PENINSULA BIBLE CHURCH INC 22 DIGITAL DR DATE ISSUED:01/29/2014 OWNER'S PHONE: 4082027870 NOVATO,CA 94949 PHONE NO:(415)506-0400 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑ ('`� Q —7 INSTALL(N)FOUNDATION CLEANOUT IN FRONT OF License Class `r Lic.# V ��3`J l PROPERTY Contractor ak, Q.,✓r%+ ,Date � Z� c 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. 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:$1680 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:31602085 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 FRO ALLED 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 Z with all non-points ce regulations per the Cupertino Municipal Code,Sect 918. RE-ROOFS: Signature A Date ��1 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. El 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 Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 505,25 3,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this �Gl Owner or authorized agent: Date: Y2 permit is issued. 4 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 GENERAL PERMIT APPLICATION � MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION \ O 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 M I C rd (408) 777-3228•FAX(408)777-3333•buildinaCcDcupertino.org \ �Ut?FEt` t IN0 ®PLUMBING ❑MECHANICAL ❑ELECTRICAL []MISCELLANEOUS PROTECT ADDRESS /\ J� I APN# 6 O Z _0 Z S OWNERNAME ( ' `�U GLS M� �,►W Y W� PHONE `IO D 20 '� 0 O B NAII STREET ADDRESS • CITY,STATE,ZIP I FAX 10(0O\ �• ��a �;fW QSn1y CONTACT NAME PHO 40$ J'\ 3 ^�S-?` E-MAIL �btir �aSS; 1 STREETADDRESS CITY,STATE,ZIP FAX ❑ OWNER '❑ OWNER-BUILDER ❑ ORRC'ERAGENT ;9+CONIRACTOR ❑COIMACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME_ LICEIyS�ENU Z ^S LICENSE TYPE BUS.LIC# CO ANY NAME E-MAIL FAX S ET ADDRESS CITY,STATE,ZIP 11 j PHONE CIN- ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME EMAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN wn.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL 'URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO FICHLEP HOME? ❑NO DESCRIPTION OF WORK o•,. wo r� TOTAL VALUATION: 1 7 �j ELVED_ IM Y_ HHHH l O O :' By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prope mer's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws reZn buildi g constructs I authorize representatives of Cupertino to enter the above-i notified p operty for inspection purposes. Signature of Applicant/Agent: ` Date: ja1 PLEMENTAL INTFORMATION REQUII2ED n �r M . '�1 ave gal couR v � salin � O 4 -WR - NIS AfEPMfsa4pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10601 NBLANEY AVE DATE: 01/29/2014 REVIEWED BY: MELISSA APN: 316 02 085 BP#: *VALUATION: 1$1,680 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION 1 CPSS USE: Commercial Building PERMIT TYPE: WORK INSTALL N FOUNDATION CLEANOUT IN FRONT OF PROPERTY SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PCSEWER 1 # $24 g TOTALS: $24.00 �• Me-A Plan Check Plumb.Plan Check 0.0 hrs $0.00 Dec.Plan Check ;b2ech.Permit Fee: Plumb.Permit Fee: IPPERMIT Glec•. Permit Fee: FC)ther lfcch.Insp. Other Plumb Insp. L.0 hrs $47.00 Other Elec.Insp. _ljech.Insp.Fee: Plumb. Insp.Fee.: Glee.Insp. Fee: NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/131 FEE QTY/FEE MISC ITEMS Plan (.;'heck Fee: Supp 1. PC:'Fee PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee PME Unit Fee: $24.00 PME Permit Fee: $47.00 Construction .Tax.- Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes 0 No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRA VDOC $47.00 Strong Motion.Fee: 1BSEISMICO $0.50 Select an Administrative Item Bldg-Stds Commission Fee: IBCBSC $1.00 INAN ky e $163.50 $0.00 res " aQ.' IEEE $163.50 Revised: 01/15/2014