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14020040\I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10251 MILLER AVE CONTRACTOR: BAYSHORE PLUMBERS PERMIT NO: 14020040 OWNER'S NAME: KHAIT ALEXANDER AND MARINA PO BOX 2579 DATE ISSUED: 02/05/2014 OWNER'S PHONE: 4088283847 MENLO PARK, CA 94025 PHONE NO: (650) 323-6464 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ REPLACE WATER LINE FROM METER TO FOUNDATION License Class Lic. # �1"` D APPROX Contractor day 0V -e P �Lk K,loerj6ate Felt Zp (f I 60 FT 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: $2700 have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 36942002.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this 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 F ST 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 Issued by: Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9 18. Signature 4 JIV Date Q RE -ROOFS: 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. E-1OWN R -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 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 Owner or authorized ager Date: 2 l 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 PERMIT APPLICATION �D COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(acupertino.ong \� V M -lRTd—TnAT F-11;7Fr-MTrAT MMTCCRT-LANEOUS MEP MISC LJ YLUY1bnNl7-- PROJECT ADDRESS 10251 0 2 5 1 M i l l e r.-Ayt , J APN # PHONE OWNER NAME Jim STREET ADDRESSC Miler ire. Y, STATE, Ip. FAX ��, (' 0(5ntt CONTACT NAME •-p-P- r l A PHONE G�� tPLf1 E-MAIL STREET ADDRESS P-01 221�Q (- 1 � s pr) ST ZIIP ^, A q 1t(� AG FAX ❑ OWNER E3OWNER` -BUILDER OWNER AGENT ❑ CONTRACTOR COhTRACTORAGENT [3ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME n ^ b rQ u m b LICENSE NUMBER b i� 7 LICENSE TE BUS. LIC # COPAY NAME M N E-MAIL FAX STREET ADDRESS l [Zpt i SD Vl C c ST Q �t ZC)({ ARCHTTECT/ENGINEERNAME LICENSE NUA4BER BUS. LIC # COMPANY NAME E-MAIL. FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT INWI DLAND ❑ YES 'URBAN DUERFACE AREA NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO BUILDING: ❑ COMMERCIAL ❑ DESCRIPTION OF WORK b44- VV t ( k k-` mw vv e r u v> a -H v pL ry 6C)44 - so TOTAL VALUATION: 2 l �O �-yEXx ME fl5r 01 iso °J��3. By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner'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 relating to building construction. I authorize representatives of Cupertino to enter the above -id en o d pro erty for inspection purposes. cot Signature of Applicant/Agent: A Date: S PLE INFORMATION REQUIRED 5 fAL 111- 10- _ ? XPI�S.S hc-" STDA72I)fi�� Y Ste-_ � ''' MAJORMl WE MEPMiscApp_2011.doc revised 06/21/11 ,� � � CITY OF CUPERTINO 1 FFF. F.MMATOR — BUILDING DIVISION kalADDRESS: 10251 MILLER AVE DATE: 02/05/2014 REVIEWED BY: MENDEZ MISC ITEMS APN: BP#: *VALUATION: 1$2,700 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex Suppl. PC Fee: (j) Reg. ® OT PENTAMATION PERMIT TYPE: 1 RPD 4 WORK re lace water line from meter to foundation approx 60 ft PME Plan Check: SCOPE $0.00 a .i ns i1_ a`t_ t rrrr�t Fee Plumb. Plan Check 1 0.0 1 hrs $0.001 1, /ec 110n Plumb. Permit Fee: IPPERMIT ?";r , 1. f,.e,: Other Plumb Insp. F0.01 hrs $47.00 1"W11l1 71'.jp, Fee: tNfi. 1.n4p1 t C,' NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Pire, NanuaryFewer [)Istrlct, ,cnool n. _ ml_ ., t R.. ...4 ,.- ♦I... .,R.,.,.. ....£ «w.nf:n e. nvn:)n61n s.d n o nnly nrr ocfimnta f'nntnrt tho vont fnr nddn'1 infn_ FEE ITEMS (Fee Resolution 11-053 Eff. 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.001= # $47.00 Plumbing 1PREPPIPE Piping, Area Suppl. PC Fee: (j) Reg. ® OT 1 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 (1_0n,�fr rr('iirjr; o'.11. T -F Administrative Fee: IADMIN $44.00 0 Work Without Permit? ® Yes Q) No $0.00 Advanced Plannin& Fee: $0.00 Select a Non -Residential Building or Structure 1 E) 0 i Travel Documentation Fee: ITRAVDOC $47.00 Strong; Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 $139.50 $47.00 TOTAL FEE•' $186.50 Revised: 01/15/2014