14060003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21086 RED FIR CT CONTRACTOR:GREENFIELD PLUMBING PERMIT NO: 14060003
OWNER'S NAME: MOINZADEH NASSER AND MARYAM 3513 MADRID DR DATE ISSUED:06/02/2014
OWNER'S PHONE: 4083078998 SAN JOSE,CA 95132 PHONE NO:(408)921-8980
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
COPPER RE-PIPE,INTERIOR ONLY
License Class Lic.#��IL �—
Contractor Dat
I hereby affirm�t at 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:$2500
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:35905051 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 IT 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 D LA ED 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 / ('
granting of this permit. Additionally,the applicant understands and will comply ued by:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
R OOFS:
Signature Dat a All roofs shall be insp 'ted prior y roofing material being installed.If a roof is
installed without first o g an inspection,I agree to remove all new materials for
inspection.
13NER-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
1,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 the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
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 ,� M I Sdoh,
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ��
(408) 777-3228•FAX(408)777-3333•buildino(c)cuDer inO.Org ,
elJPEEt`CIC`t0
/PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS i r I APN 3s�?" OS
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STREET ADDRESS CITY,STATE, ZIP FAX
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COI�TIRACTOR Ih SNE LICENSE NUMBER LICENSE TYPE BUS.LIC n
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AR CHrMCT/ENGINE't.R NAME LICENSE NUMBER BUS.LIC n
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAIZLY PROJECT IN WILDLAND ❑ YES PROJECT N ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMMCIAL I URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOT.AI.VALUATION.
By my signature below,I certify to each of the following: I am the property o,%amer or authori agent to afF5n the pro er's alf. ,,e read this
application and the information I have provided is correct. I have read the Description of Work and verify it is a e. I agree omply vet applicable local
ordinances and state laws relating to building construction. I author' o res tatives of Cupertino to enter the above-id red r r inspection purposes.
S i--nature of Applicant/Agent: Date: r-
SUPPLEMEI\rTAL II\IF RE
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MEPA1isa4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21086 RED FIR CT DATE: 06/02/2014 REVIEWED BY: MELISSA
APN: 359 05 051 BP#: *VALUATION: 1$2,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPR i
WORK COPPER RE-PIPE INTERIOR ONLY
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Re-Pipe Interior 1PRREPIPE 1 # $14
TOTALS: $14.00
-7 gq .�
;k/,—'O. illfvl Ckw(,k Plumb.Plan Check 0.0 hrs $0.00 P ifel
_tkc a. F a>,'rtZiG Fee: Plumb.Permit Fee: IPPERMIT /A' /em tr
7r acZ ;tl,rxa. larszt. Other Plumb Insp., 0.0 hrs $47.00 oits,
�lczc'z. iL11J. I Ccz: T7ur;A Iiasp. Fee
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 prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711113) FEE QTY/FEE MISC ITEMS
Plays Check P*'�&':
suppL /'(, e
PME Plan Check: $0.00
PME Unit Fee: $14.00
PME Permit Fee: $47.00
£:Oaisty""'c tion
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRAVDOC $47.00
Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
BN OR $153.50 $0.00 TOTAL FEE: $153.50
Revised: 04/01/2014