14010026 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10164 S FOOTHILL BLVD CONTRACTOR:MIKE COUNSIL PERMIT NO: 14010026
PLUMBING INC
OWNER'S NAME: JOAN THOMPSON 1915 O'TOOLE WAY DATE ISSUED:01/06/2014
OWNER'S PHONE: 4082522910 SAN JOSE,CA 95131 PHONE NO:(408)272-4900
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
License Class
1 �y 1 REPLACE(E)WATER HEATER,SAME LOCATION
� ULic.#�� t 2 J 1
Contractor A X11k l aj,,A.Sl X Date 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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2850
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:35701091 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 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 AS 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 the1
granting of this permit. Additionally,the applicant understands and will comply Y Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
918.
RE-ROOFS:
Signature
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
J 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. 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,Section 25505,25533,and 25534. '�
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:I w
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
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 O\
(408)777-3228•FAX(408)777-3333•building cDcupertino.org MISC
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PLUMBING
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❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAME �(� �,/�/( 0/1 LIC SE ER L CENSE E BUS.LIC#
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ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC It
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STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT INWI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK M .kZ (A i
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TOTALVALUATION: „ z - -- A0
By my signature below,I certify to each of the following: I am the property owner or authorized agent ct on thes be ave read this
application and the information I have provided' correct. I have read the Description of Work and verify it is accurate. I agov omply with all applicable local
ordinances and state laws relating to it ' traction. I autho r �atiyes �uerlmo to enter the ve-identified property for' p ction purposes.
Signature of Applicant/Agent: Date:
SUPITENTAL IF TION QUIRED t
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10164 S FOOTHILL BLVD DATE: 01/06/2014 REVIEWED BY: MELISSA
APN: 35701.091 `VALUATION: 1$2,850
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Du IeX PENTAMATION PRWHEATR
USE: p PERMIT TYPE:
WORK REPLACE E WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE_ FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $28
TOTALS: $28.001 - is
as s 4 x ,
Xkc:h. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec..Plan Check
kch.Permit Fee: Plumb.Permit Fee: IPPERMIT 1 lec.Permit Fee:
Llf,"',h.
Alerch.Iresp. Other Plumb Insp. 0.0: hrs $47.00 Chher Etce.Insp. Li
Insp.l("'e: Plumb. Insp.Fee: Elec.Imp.fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc). These _f
-fees are based on the relimina information available and are on l an estimate. Contact the Detor addn'1 info,
FEE ITEMS jFee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC F'ee
PME Plan Check: $0.00
Permit Fee:
Suppl. Inas)Fee
PME Unit Fee: $28.00
PME Permit Fee: $47.00
Construction Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes (E) No $0.00
Advanced Pla ming Fees:
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
Nom;
gr � $167.50 $0.00 �T'O° $167.50
Revised: 10/01/2013