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14010010 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10820 SANTA TERESA DR CONTRACTOR:RED ROOTS MASONRY PERMIT NO: 140 100 10 INC OWNER'S NAME: JANET M VERSON PO BOX 315 DATE ISSUED:01/02/2014 OWNER'S PHONE: 4083430054 SAN MARTIN,CA 95046 PHONE NO:(408)683-4556 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT I— PLUMB � License Class C IC-7A Lic.# 4tS T$4t 6 MECH r- RESIDENTIAL F— COMMERCIAL r Contractor (Lek &-A I r 4 ,"A tr1 ate I—2 ^Z0144 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION-INSTALLATION OF GAS LINE TO PREFABRICATED FIRE (commencing with Section 7000)of Division 3 of the Business&Professions PIT Code and that my license is in full force and effect. 100 LINEAR FT 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. 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 Sq.Ft Floor Area: Valuation:$1500 permit is issued. APPLICANT CERTIFICATION APN Number:35613013 00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9 18. � Issued by: _ 'TG Date: Signature�/�ij /i Date /-- 2✓L6/y ❑ OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date- ],as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of Califomia. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Owneyor auth7ized agent r forthwith comply with such provisions or this permit shall be deemed revoked. �lr/bt�k sr- NJ"v*_ Date: ^Z APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.1 agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION all non-point source regulations per the Cupertino Municipal Code,Section 9 18. I understand my plans shall be used as public records. Signature Date Licensed Professional r GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �/, /�`� /�v�l�� (408) 777-3228•FAX(408)777-3333•building(a�cupertMISC ino.org O FOPLUMBING ❑MECHANICAL ❑ELECTRICAL ✓/❑MISCELLANEOUS PROJECT ADDRESS APN# OWNER NAME PHONE �J •l r J E-MAIL -1 1 � C Z),C- STREET ADDRESS / CITY, STATE.ZIP.. I FAX CNIE PHONE E-M•� rcl o l �� e� STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT C NTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS.LIC# b, C C NAME FAX ? f STREET ADDRESSCITY,STATE,ZIP PHONE e L 1 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WBALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: CONMIERCW. URBAN WTERFACE AREA NO FLOOD ZONE NO EICI�.ER HOME? NO DESCRIPTION OF WOR t n Q TOTAL VALUATION: NINE 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 QW-02t. 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 buildin c' I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Date: Signature of Applicant/Agent: S EMENTAL INFORMATION RE UIRED Q -.�� oFFse>:13JSIAivtir��; EXPRESSWIN ' plasm Ems- ��^T A9/Ti -'ham• � MEPMisctlpp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10820 Santa Teresa Dr DATE: 01/02/2014 REVIEWED BY: Sean APN: BP#: oD/o *VALUATION: $1,500 7 LZ *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 RPGA WORK Installation of gas line to prefabricated fire pit 100 L.F. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1 PGASRES 1 # $70 TOTALS: $70.00 �f A,`,aar Check Plumb.Plan Check 0.0 hrs $0.00 ra<, t h o Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. hrs $47.00 0.0 NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Thesefees are based on the preliminar information available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS(Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS Plan C'heekf;ee: ))PME Plan Check: $0.00 PME Unit Fee: $70.00 PME Permit Fee: $47.00 Co rU�, 717'0,1'17',01': Administrative Fee: 1ADMIN $44.00 Work Without Permit? 0 Yes (F) No $0.00 Travel Documentation Fee: ITRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $209.50 $0.00 TOTAIs FEE:` $209.50 Revised: 10/01/2013