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14050126CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10300 STERN AVE CONTRACTOR: THOMAS PLUMBING INC PERMIT NO: 14050126 OWNER'S NAME: RAY ERNEST F AND KATHERINE L TRUS 16305 A VINEYARD BLVD DATE ISSUED: 05/21/2014 OWNER'S PHONE: 4082520685 MORGAN HILL, CA 95037 PHONE NO: (408)736-3050 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑ REMOVE AND REPLACE WATER HEATER /t ��y License Class C� " ^� Lic. # 3T1 (r�B �% Contractor Date --� I hereby affirm that I am licensed r rder 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 Sq. Ft Floor Area: Valuation: $800 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 APN Number: 37514034 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 j 180 DAYS Fl� •y_ � $T CALLED INSPVCT,ION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the / / Date: U granting of this permit. Additionally, the applicant understands and will comply Issued by: �� `' J, (I with all non -point source regulations per the Cupertino Municipal Code, Section 9 18. K_ h1lRE-ROOFS: Signature vL.� 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. 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 Section 3700 of the Labor Code, for the performance of the work for which this the Health & Safety Code, Sectio 255 5, 255 nd 25534. C r Owner or authorized agent: 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 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildinala cuoertino.org 013TTT1,AMrnTr- 1-7 iA7ry A -kTyr A 7 7P.T.I=.=TCAT_ nMISCELLANBOUS MEP MMM tSC PROJECT ADDRESS u - — I APN J 4 u OWNER NAME M, S STREET ADDRESS CTTY, STATE,ZIP.. I FAX CONTACT NT -AME PHONE E-IvLAII STREET ADDRESS CITY, STATE, ZIP FAX ❑ 0-Alsz '❑ OV,11 -R-BUILDER ❑ OR'ITRAGFBNTt CONTRACTOR ❑ CONTTRACTORAGENT ❑ ApM=CT ❑ ENGINrx.R ❑ DEVELOPER ❑ TENANr CONTPA RNAME LICENSE TYPE BUS. LIC# 1 COMPANYNANEI II /�tI F�771 S AD Weld, CITY, STATE ZIP ` , (�Q l �/ O -7 ARCHITECT/ENGINEERNAME LICENSENUMBER I BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE . USE OF ❑ sFD or DUPLEX ❑ m=i-FAMQ Y BUIL.DJNG: COMMERCIAL PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES I URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HMM? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION, aRECEI r;F?re�-S Yah"^".- .=.�:e•'-' ..ori -a. _,:': By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property ` er's behalf. I have read this application and the information I have pr vided is correct. have read the Description of Work and verify it is accurate. I agree to comply v,ith all applicable local ordinances and state laws relating to b n c t actio . I authorize representatives of Cupertino to enter the above,-ide tified property for inspection purposes. Signature of Applicant/Agent; Date: SUPPLEMEI\TTAL INTFOR 4ATION REQUIRED of sr SLY - �- OS�'u rum C�I+3sTE , —�- INi-- O ._ .AltEPMisc4pp_201 1. doc revised 06121/11 CGJ-4I ��, �� CITY OF CUPERTINO 1UUU Ucrrrn4A9rn112 _ RTT11.T1TN('i DIVICICIN ADDRESS: 10300 stern ......•.»•. •. w•_.. FEE DATE: 05/21/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: $800 xPERMIT TYPE: Building Permit 0.0 PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PME Plan Check: PENTAMATION PRWHEATR PERMIT TYPE: USE: Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs WORK remove and replace water heater PME Unit Fee: $0.00 PME Permit Fee: $47.00 SCOPE consvuction Tax: vkcir. Plan Check k Plumb. Plan Check 0.0 hrs $0.00 Piec 6 ecir- Per;;tii Fees Plumb. Permit Fee: ]PPERMIT 1=7' trt.E � reg. rr. 7:is,_ her Plumb Insp. 0.0 hrs $47.00 t1rl,E�, f <.e_ Irbsh�_ -1arlt. frts �. L°ec !'r'as OJ, h,t p. Fee: NOTE: This estimate does not include fees due to other vepartments (Le. rianning, ruarsc rr urna, c, ru" u,y _ .. _� •�..xi,. ,...,f ,.,.,, „„t,..,„ r:„,,,te /'nntn,•t fbo Want for addn'1 info. vlstrlcf, etc.. tnese ees "re uuaeu urt uoc ,oe.,,„,,„, FEE ITEMS (Fee Resolution ILL Ef . 7./Ul3) ......•.»•. •. w•_.. FEE - _-__ _. _ QTY/FEE ____ ___ ___ MISC ITEMS Plan Check Fee: $0.00 0 # Plumbing $28.00 ]PRWHEATR Water Heater Suppl. PC Fee: e) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 consvuction Tax: Administrative Fee: ]ADMIN $44.00 G Work Without Permit? 0 Yes (E) No $0.00 Advanced Plannin& Fee: $0.00 Select a Non -Residential Building or Structure, Travel Documentation Fee: ITRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg* Stds Commission Fee: 1BCBSC $1.00 �m COALS . $139.50 $28.00 TOTAL FEE: $167.50 r,evisea: u4/u uzu ,+