The URL can be used to link to this page

14010025CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21456 RUMFORD DR CONTRACTOR: MIKE COUNSIL PERMIT NO: 14010025 PLUMBING INC OWNER'S NAME: GAIL LEE 1915 O'TOOLE WAY DATE ISSUED: 01/06/2014 OWNER'S PHONE: 4082576745 SAN JOSE, CA 95131 PHONE NO: (408) 272-4900 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL REPLACE (E) WATER HEATER, SAME LOCATION j'j�1�� -1 l License Class AQ 11 Lic.#(0 Q/` Contractot*Wl +U �CJ�NLS� Date VA t I hereby affirm that I am licensed under the provisions of apter 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 Sq. Ft Floor Area: Valuation: $3818 rformance of the work for which this permit is issued. 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: 32641007 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 DA ERMIT 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 DAY 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 Is Date: 6 114 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 918. RE -ROOFS: Signature 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. ❑ 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. 1 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 Section 3700 of the Labor Code, for the performance of the work for which this the Health & Safety Code, Sections 25505, 25533, and 25534. }� Dater) Owner or authorized agent: permit is issued. 61�— 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 918. Signature Date PERMIT APPLICATION Oti GENERAL PE O MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION O` 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building ancupertino.org \ r� . .. r-71 — A —. AT I—I77TTZr'ruT(-er nMTS-RT-LANEOUS YLU1v1D1114U - LJivilJValt'a- u�-•�------ `� --- APN# 3 26 Lit -(no, -- PROJECT ADDRESS L I �S ��J , �` , ` ' C'v Y C, �Y1( OWNERNAME ` PHO t (� 2;�- 76 4S. E MAII STREET ADDRESS e / _ 0 wlo� CTTY.,ZIP. r A qS0 I I FAX CONTACT NAME ' PHONE 0 Z 51- (!t E-MAIL STREET ADDRESS, &V L CITY, STATE, ZIP U C142L-ii VIC Q,4 FAX ❑ OWNER '❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNANU Coo yk ` l LIC ' E NUMBER 'I 2 CP LICENSE TYPE v BUS. LIC # COMPANY NAME M ., E-MAIL FAX STREET ADDRESS owsC U ^ ^ •7� X CITY, STATE, ZIP A q 2 �� \ 1 J I 7 PHONTE ARCHTTECT/ENGI EERNAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX❑ MULTI-FAM¢.Y PROJECT IN WIIALAND ❑ YES URBAN INTERFACE AREA NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN El YES EICHLER HOME? ❑ NO M BUILDING. ❑ COMERCIAL ❑ DESCRIPTION OF WORK 0. - TOTALVALUAnMN: By my signature below, I certi to each of the following: I am the property owner or authorized agent to act onperry owner's behalf. I have read this application and the information I have provi d 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 relati ng c nstruction. I au Ize resentatives of Cupertino to enter the ve-identifi property fo inspection purposes. Signature ofApplicant/Ag ent: Date:-\C)I- 60 SUPPL MEN AL INFORMATI Q OFFICE USEOl�I Y� ' p, x.. � SLR THI+<COUAT�R tM _E _ r�xU.-'STAI�73ARD" a 010 W, 05 A4FPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FRE F,STIMATOR — BUILDING DIVISION im,ADDRESS: 21456 RUMFORD DR DATE: 01/06/2014 REVIEWED BY: MELISSA Placa Check Fee: APN: 326 41 007 BP#: `VALUATION: 1$3,818 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex PME Plan Check: PENTAMATION PERMIT TYPE: PRWHEAT WORK REPLACE E WATER HEATER SAME LOCATION SCOPE .Suppl. Insp Fee APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $28 TOTALS: - -- $28.00 Z Eli' 5 Mech. -Plan Check Plumb. Plan Check 0.0 1 firs $0.00 Elec. Plan Check Ltech, Permit Fee: Plumb. Permit Fee: IPPERMIT Glec. Permit Pee: Other ,tlech. Insp. Other Plumb Insp. 0.0 hrs $47.00 01her Glee. Insp. Alech. Insp. lee: Plumb. Insp. Fee: Elcc. Insp. lee: 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 prefindna information available and are only an estimate. Contact the De t or ad&t7 info. FEE ITEMS (Fee Resolution 11-053 E . 711113,) FEE QTY/FEE MISC ITEMS Placa Check Fee: Suppl. Pt: Fee PME Plan Check: $0.00 Permit Fee: .Suppl. Insp Fee PME Unit Fee: $28.00 PME Permit Fee: $47.00 Consiruction T ax. F T Administrative Fee: 1ADMIN $44.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning, Fees: Travel Documentation Fee: 1TR4vDoC $47.00 Strong Motion Fee: IBSEISMCR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 M1_ $167.50 t $0.00 $167.50 Revised: 10/01/2013