14020108 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10397 AMISTAD CT CONTRACTOR:MARTI'S PLUMBING PERMIT NO: 14020108
OWNER'S NAME: VIVEK JAIN 171 BRANHAM LN STE 10-418 DATE ISSUED:02/19/2014
OWNER'S PHONE: 4082036689 SAN JOSE,CA 95136 PHONE NO:(408)375-3190
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
REMOVE AND REPLACE 75 GALLON GAS WATER
License Class L1 3 41 /y1Liic..##��/meq5502-0
/5 5 0 2 0 ,f HEATER
Contractor V CZ( rr177T`I�N✓Date 2rf�'_1l
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
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:34245010 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 ORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITfIIN 18 AYS OF P 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 M ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, nn
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 r the Cupertino Municipal Code,Section
918. ;OC
RE-ROOFS:
Signature �/ Date 2 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 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,S ' ns 25505, 5533, d 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 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 � MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION VO
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408) 777-3228•FAX(408)777-3333•building aacupertino.org MISC
�IJI?IrF2't'!h!O
PLUMBING ❑MECIiANICAL ❑ELECTRICAL ❑MISCELLAIIEOUS
PROJECT ADDRESS APN# 2 � r\10
OWNER NAME \f i v'e( _ :^C I l�" PHONE /US-20(a oc -7 E-MAIL (�
STREET ADDRESS`+ \ �\ `•J CITY STATEIZIP.. FAX
D"Al AM(STA.0 eT- n�YLrw�—C A 4 sCIi q N
CONTACT NAME O/ ,^n PHONEgv jg�- 510" 55 Z E-MA L
STREET ADDRESS CITY,STATE, J FAX
❑ OWNER '❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
d /7 LICENSIEry�� LICENSE E BUS.LIC#
vtG�n _ A4 AreZ l02-O �
COMPANYNAME T !S 021f IN 11
FAX
STREET ADDRESS tl�tO !{4L . CITY,STA ZIP PHONE T?/t-0
ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPI ER ❑ MULTI-FAMILY PROTECT•IN WI DLAND ❑ YES PROTECT IN ❑YES IS THE BLDG AN ❑
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA DIO FLOOD ZONE C!}NO EICHLER HONIE7 NO
DESCRIPTION OF WORK -7 ^_J Z-O AJ
�C'EPG 11 eFM E/V -,
�"URNMi IM
TOTALVALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to a the property o'kAmer behalf. ave read this
application and the information I have provided is torr ct. I have read the Description of Work and verify it is accur ply with all applicable local
ordinances and state laws relating to ' g constr. ion. I izrrepresentatives of Cupertino to enter the above-identified propertyforfor inspection purposes.
Signature of Applicant/Agr ent: (n-� Datej�—
SUPPLEMENTAL INFORMATION REQUIRED oFFrcE USE oL `
CO.ITLt^_TER
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A EPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10397 amistad ct DATE: 02/19/2014 REVIEWED BY: mendez
APN: BP#: VALUATION: $2,700
YPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION PRWHEATR
USE: SFD or Duplex PERMIT TYPE: i
WORK remove and replace 75 gallon gas water heater
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $28
TOTALS: $28.00
I` ' a
r
Plumb.Plan Check 0.01 hrs $0.00
Plumb.Permit Fee: IPPERMIT
t}rtt� �;,.;Yiy,s >. Other Plumb Insp. 0.0 hrs $47.001.rc>�
Imp, t ice
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 Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711/13) FEE QTY/FEE MISC ITEMS
Man Check
Suppl. /'C:]"(W
PME Plan Check: $0.00
PME Unit Fee: $28.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes Q No $0.00
riC�L'CJrIt'e l Pltt7'fniaii Fees:
Travel Documentation Fee: ITRAVDOC $47.00 i
Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
�x
..w4
$167.50 $0.00 x TOTAL FEE: $167.50
Revised: 01/15/2014