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14100017 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10225 ANTHONY PL CONTRACTOR:BURKETT'S POOL PERMIT NO: 14100017 PLASTER INC. OWNER'S NAME: MINOGUE DAVID 600 N FRONTAGE RD DATE ISSUED: 10/03/2014 OWNER'S PHONE: 6505448005 RIPON,CA 95366 PHONE NO:(209)529-6944 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ p INSTALL GAS LINE FOR REMODEL OF POOL-SEE License Class Lic.# (oO 6 �$Z PERMIT# 14030173 Contractor 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:$0 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:34212075 00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT7DAYS ORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WIT 180ERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enterupon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS CALLED 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 l(S 3 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9 18. RE-ROOFS: Signature Date -34 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 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. 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,Sections25505 33,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dater u•3_�f 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 CENER—AL Pc4MI► APPLICATION /` CONiNiUNIiY DEV=LOPf��ENT DEPAP,i IdiENT•BUILDING DIVISION \ 10300 i ORRE AVENUE• CUPER i INO, CA 95014-3255 (408) 777-3228•FAX(403)77-3333•building aa..cuoetno.ora MISC �\ etJrE��C�C> 1 ❑PT—T IsNG ❑h C'r:-1�iC.tL ❑E7ECnUCpr �II;1 CBCT A��Ot S ;?R0;cl,ADD-ESS l U Z2 a H Its]: 2 1 Z 0 �S PHo].. �,m-i AMP SS a \ Com',STATE,Zia. FA I I CON-M CT NJUIS I ?"HON I =lJt_ SIR,_:ii ADDRESS I CST;',STAT.:, ZI I FAX 13 cvwc-p •❑ OJ° x-3t T-DER ❑OJ.T-ti Aam ❑ Cmap 4C'Oi2 ❑CDhTp SCTOR 4�.T ❑ 1-a=--,--CT ❑�C-3 i. ❑ D �O?? ❑^?.�±'I CON-ACTOR]�A]� 1 LiC NSEMnarzR iIC SEi?_ 3-0s.LIC COIJDAhYHatJ? l I _tJ�II I Pp STR:7-TADDRE.:S ( CITY,STATE,ZIP I PHONE �Clui CAASe N!,1Jy I LiCr-I SE]4UT ER. I BUS.LIC CONPfNY•N IM I E-bfiAII, I FAX ST3.--T ADDPMS I CITY,STATE,ZIP I PHOh:- 'USB OP ❑-sm or DiJPLc.. I❑ hams-i &LY I MoJECT LN W3LDL '\M ❑ YES I PROTECT N, ❑YS I IS T:i BIZO AN ❑ YES BUMDT-N : ❑COWJzmcl"LT�n3 t?Q St+�tFAG AP A ❑ NO Z OOD ZA]L ❑NO LiGsuZ HOMMM ❑ NO DIEXPUTION OF WORK '.+._ -_ � _wFem ;��.,"ice-"�'-.._.�-'_"'-=M,.. ;- �.r L OTFT W UAiION: By my sip at'Jre below,I ce;:I�to each of the-follvwing: I mm the Property o;;'ner or aL horiwd agent to act on tie-propery mvner�s behalf. I have read this application and the information I have_provided is correct I have read the Description of Work and veriy it is accux,ate. i a_*ee to ce*aply vrith al]app lica is local ord nances and s=tela„tis rel€ti e to b 11d _ JC)Or4 I vu�lOT:Zt rP.preSented-VCS of C ptimino to enter the abovt-1den-ti �d pl07erCj f0i L FC�On pL'pOS.S. S i or Applicant?.E?.ni: Date: SUPT E qff MM --�— Yt �_ W rff OEM h- A/Lm/.pp 2011.coc ravised 06/=1/II CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10225 anthony pl DATE: 10/03/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: $0 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair PRIMARY SFD or Duplex PENTAMATION USE: p PERMIT TYPE: 1 RPGA WORK �Anstallgas line for remodel ofpool-see permit# 14030173 SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $72 TOTALS: $72.00 erg i"= c 'S' saaaa_ sa'�` a WE Plumb.Plan Check 0.0 hrs $0.00 0"Ie:k b7ecl,_ 1'r>t°,ttrt Fete: Plumb.Permit Fee: IPPERMIT 0' 1"'rrrit 1"v". ?rare= iEt°fir. 1r?srr_ Other Plumb Insp. 0.0 hrs $48.00 oih('>!'!; °' h7sl: