14050057 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10557 RANDY LN CONTRACTOR:CMS PLUMBING PERMIT NO: 14050057
OWNER'S NAME: PAULSEN GEOFFREY L AND JANINE 3891 CAMDEN AVE DATE ISSUED:05/08/2014
OWNER'S PHONE: 4084807509 SAN JOSE,CA 95124 PHONE NO:(408)828-6700
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL F]
INSTALL GAS LINE FOR LAUNDRY AND GAS STOVE,
License Class L 3 Lic.#�t3 ( REPIPE
44 Contractor raw _Date d
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:$4800
ve and will maintain Worker's Compensation Insurance,as provided for by
e tion 3700 of the Labor Code,for the performance of the work for which this APN Number:31602053 00 Occupancy Type:
it is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
orrect.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 DAY FR M LAST CALLED IN SPE TION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, p
costs,and expenses which may accrue against said City in consequence of the Issued by: Date: Q ��
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
g� RE-ROOFS:
Signature Date CJ 1 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. 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 Cu ertmo Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 55 533 a�n255�3
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ag 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 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
9 18.
Signature Date
GENERAL PERMIT APPLICATION /� ME P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION dh
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
408 777-3228-FAX(408)777-3333•buildino(8CUDertino.or4
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CUPE=RTEt+tO \
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLAN/EOwUS
PROTECT ADDRESS 1055-1
0 5 3"'1 '2 Q� t L^ I APN-9
OVTAERN41✓.E HONE
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STREETADDRESS I CrrY, STATE,ZIP_. I FAX
CONTACT NAME PHONE
STREET ADDRESS CITY,STATE,ZIP FAX
❑ ORTIER ❑ O11AWM-BURDEK ❑ OWNIERACE17 ❑ CONTRACTOR ❑CONiRACTORAGENIT ❑ ARIMUTECT ❑ENMIZIMR ❑ DEVELOPER ❑TENANT
CONTP.ACTORIh LICENSENUMBER LICENSETYPE BUS.LIC'
COMPANY NAME E-MAIL FAX
STREET ADDRESSCrt Y,STATE ZIP I PHONE
ARCHITECT/ENGINEER NAME LIMISE NUMBER. BUS.LIC 4
COMPANY NAME E-MAIL FAX
STREET ADDRESS CrrY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ Mum-FAMJLY PROJECT IN wnmLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILAINC: ❑COMMERCL4L I URBANIN LFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER H01a? ❑ No
DESCRIPTION OF WORK / `J 1 v✓Q / '�+�
VKc l r l 6a
aft ^I ,L
MO
TOTAL VALUATION: ftECE I3:B 11-
d v .. p � W,
By my signature below,f certify to each of the following: I am the property owner or authorized agent to act on e pr erty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accura . I agree to comply Mth all applicable local
ordinances and state laws relating to building c � ction. I authorize representaf f Cupertino to enter the abo� -identifieedd property for inspection purposes.
S i--nature of Applicant/Agent: Date: d
SUPPLEMENTAL INFORMATION REQUIRED
Q
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MEPAfisa4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10557 Randy In DATE: 05/08/2014 REVIEWED BY: Mendez
APN: BP#: EVALUATION: 1$4,800
%PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex PENTAMATION 1 RPGAS
USE: p PERMIT TYPE: i
WORK install cias line for laundry and gas stove re i e
SCOPE
Lf<cia l'Icr�l t Yxer_ti Plumb.Plan Check 0.0 hrs $0.00
g-ch. 1 ro t Fee: Plumb.Permit Fee: 1PPERMIT
oldwv tfech. Other Plumb Insp. 0.0 hrs $47.00 01,,7C,r 1"k"(.Insj
Heck I Pht abt Insp. Fee" Giec�, Inst), [;-,
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These&es are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/f 1113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl. PC Fee: (F) Reg. 0 OT0.0 hrs $0.00 $70.00 IBPGA 7 Piping,Gas>4 Outlets
PME Plan Check: $0.00 = # Plumbing
Permit Fee: $0.00 $14.00 1 1PRREPIPE Re-Pipe Interior
Suppl. Insp. Fee:Q Reg. OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
)IISIrlictIon 17:1:
Administrative Fee: IADMIN $44.00 0
Work Without Permit? 0 Yes (F) No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: 1TR4VDOC $47.00 Building or Structure ,
Strong Motion.Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$139.50 $84.00 TOTAL FEE: $223.50
Revised: 04/01/2014