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14040133 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21578 FLINTSHIRE ST CONT CTOR:TPERMIT NO: 14040133 OWNER'S NAME: JANICE&DAVID SEHR DATE ISSUED:04/22/2014 OWNER'S PHONE: 4088289308 PHONE NO: Ja LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL F] COMMERCIAL ❑ License R REPLACE(E)WATERHEATER,SAME LOCATION Class 0- (D Lie.# �g9 q 4 Contractor Re—i �t(, )Um6n7 Date 4J aai�I 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:$650 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:35620026 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 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 DAYSFROM D INSPE TION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ! ZZ ! granting of this permit. Additionally,the applicant understands and will comply Issued Date: with all non-pointsour 'regulations per the Cupertino Municipal Code,Section 9 18. RE-ROOFS: Signature Date 3 2II All roofs shall be inspected prior to any roofing material being installed.If a roof is Ni installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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,Section 25505,25533,and 25534. Section 3700 of the Labor Code,for theerformance of the work for which this 1 p Owner or authorized agent: IAV Date: 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 E P COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION l ` 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 \ (408) 777-3228-FAX(408)777-3333-buildinga-cuoertino.org \A misc CUPEEtTINO \_ PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 1 1 S7?; :i I(Nt 5k1,� � APN# 3-5--(/ - zo OWNER .aJ�J NAME U I/aQ 5 C b r PHO "JLY6)S 2 -q D 6(� I E-MAIL �---� STREET ADDRESS ak S-7(� T(;n+Skn 1 y p S+ C STATE. ;Vln o QA FAX 9 50 �y CONTACT NAME�V� - �-'� PHO -,WT2-4-2_0-2-9Q T7AIL t/eI VMVJ1� � Ck STREETADDRESS\qq91 FA1-� )- i Ir © CA ^ O \ �_ ( QQ 0 OWNER OWINER-BUIDER ❑ OWNER AGENT CONTRACTOR El CONTRACTOR AGENT 11 ARCHITECT 1:1 ENGINEER ❑1 DEVELOPER 11 TENANT CONTRACT NAME LICENSENUMBERq�� I LICENSL17 BUS.LIC# �30 COMP N E J `y-n ��, \` S 1Um� � rT�-lrCy='t. \` S �Um�Jf G� OD.�1.a' 1 SZIP $T�DRESST '` \IC 11� �Q�J�� LJSTATE �' (G[� (6QI�! \ENp ��J7��GQO ARCHTTECT/ENGINEER NAME LICENSE NUMBER v t J T BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF 11 SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YESrIFSICHLER THE BLDG AN ❑YES BUILDING: ❑COM!MMRCIAL URBAN INTERFACE AREA ® NO FLOOD ZONE ®NO HOME? 2 NO DESCRIPTION OF WORK 40 gakkon cA S 1 _ _ p_„ /a,Ge_ O $ ��p��v�"�." �.F"' _ r. w� �3-a. •Y,x',.i'�a T�FU^.e' ��t�-, TOTAL VALUATION. By my signature below,I certify to each of the following: I am the property owner or au ag c on the property owner's behalf. read this application and the information I ha a pr ided is.correct. I have. he Description of o a I applicable local ordinances and state laws relating ?l#.til ing constr_u tion. I auth ize epre entatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: �j Date: r SUPPLEMENTAL INFO TION REQ D = � of eE usEoril Y EVILamv � _ V.ER�TH�COL7ti'TER��,� . IINWWM EXPRESS WIN A wa �jCjJeT.ARGE kr 1 E' ' 24 IMPOSE MA70R MEPMiscApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 21578 FLINTSHIRE ST DATE: 04/22/2014 REVIEWED BY: MELISSA APN: 356 20 026 BP#: "VALUATION: $650 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: PRWHEAT A WORK REPLACE E WATERHEATER SAME LOCATION SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $28 TOTALS: $28.00 t,cir. Flare k Plumb.Plan Check 0.0 hrs $0.00 ',11,111 Pe;—nil Fee: Plumb.Permit Fee: IPPERMIT , 1'0 , �- LiOther Plumb Insp. 0.0 hrs $47.00 0rhur 1;wf.1n-v,, FF Prrrndl). TnsE. 1 s e: I>iec. Imp i e NOTE: This estimate does not include fees due to other Departments("tie.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 addn'l info, FEE ITEMS 666 Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS Plarl (,, lheck Fee: SlyrpL PC PME Plan Check: $0.00 SarpPI, hlsp 'e€� PME Unit Fee: $28.00 PME Permit Fee: $47.00 C,r"rt2.Stf7tt'I CJi1 ' Administrative Fee: 1ADMIN $44.00 Work Without Permit? 0 Yes 0 No $0.00 =1r,/�c�rrc'crc//'(rrnnl'Ig fees: Travel Documentation Fee: 1TRAVDOC $47.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 ITP` EA $167.50 $0.00TOTAL FEE:" $167.50 Revised: 04/01/2014