14030035 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10888 SYCAMORE CT CONTRACTOR:GREAT AMERICAN PERMIT NO: 14030035
PLUMBING CO INC
OWNER'S NAME:
SAN JOSE,CA 95159 PHONE NO:(408)279-1515
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E]
REPAIR 3" GAS LINE UNDER HOUSE
License Class_ Lic.# 96 t6&�::
Contractor p4/ W ,2(Cd¢pLt,lg.6 Wate 3'�
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:$1000
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:34257037 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 WITIIIN 180 D F 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 OM LAST CALLED INS P CTION.
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 Issued by: Date.
with all no -point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signat 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.
17 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 Cod2STRUCT!ION
!LENDING
533 and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this jl
permit is issued. Owner or authorized - - 6�
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 CO 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
10300 TORRE AVENUE•CUPERTINO,CA 95014-32552 O�
( )
408 777-3228•FAX(408)777-3333•buildinaCcDcuoertino.org MISC
GU��C7'IhtO 1
PLLTNOING []MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS I APN# 2 S17 2�./\�J
OWhTERNAME 1 (� PHONE J E-MAIL V
STREET ADDRESS CITY,STATE,ZIP.. I FAX
C Ul E1
CONTACT NAME PHONE E-MAII
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ O)xrNER-BUILDER ❑ OIANERAGENT ❑ CONTRACTOR ❑COITRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME LICENSENUMEER r— LICENSE TYPE BUS.LIC#
R!
COMPANY NAME E-MAIL FAX 3
STREET ADDRESS CITY,STATE, PHONE _
�
ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAM¢.Y PROJECT INWIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑CON&IERCIAL URBAN INITMFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK �j (I U N CA
tea'-„y s -..�- �,,�3p• "' -�sw�uc�'2
VALUATION: "RECEIWEDB,..,�,,.�— rte'> - ± �
TOTAL\ALUATIOA: � .� .,,.,,,� — - ->. r
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 rovided is c rT ct. 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 b din co on I uth tatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:c I
MEAITAL INFOR1vIATTON REQUIREDmy
i �
101
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A,1EPMisC,4PP_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10888 SYCAMORE CT DATE: 03/05/2014 REVIEWED BY: MENDEZ
APN: BP#: *VALUATION: 1$1,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPGA
USE: PERMIT TYPE:
WORK REPAIR 3" GAS LINE UNDER HOUSE
SCOPE
14,,;/,. 1'i(l e Plumb.Plan Check 0.0 hrs
$0.00
t;>c:la. r�it ec> Plumb.Permit Fee: 1PPERMIT Fcc.
'7 Irer i��u°ir. IY in. Other Plumb Insp. 0.0 hrs $47.00 other fsic--c_Msj�.
P,Unih, hsp. Fee: Lle,(.Ms,'), 1"v:
NOTE.This estimate does not include fees due to other Departments(Le.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 De t or addh 7 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Plumbing
Suppl. PC Fee: (j) Reg. 0 OT0.0 hrs $0.00 $70.00 IPG,4SRES Piping,Gas<=4 Outlets
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. 0 OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
("0e. 7.,;t ucflon %LVr
Administrative Fee: 1ADMZN $44.00
Work Without Permit? ® Yes 0 No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential
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
$139.50 $70.00 TOTAL FEE: $209.50
s
Revised: 01/15/2014