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14090200 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21979 SAN FERNANDO AVE CONTRACTOR:CITY OF CUPERTINO PERMIT NO: 14090200 OWNER'S NAME: CITY OF CUPERTINO 21979 SAN FERNANDO AVE DATE ISSUED:09/30/2014 OWNER'S PHONE: 4087773110 CUPERTINO,CA 95014-2823 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL E] REPLACE(E)POOL HEATER,SAME LOCATION(SLIDE License Class Lie.# POOL Contractor Date RM) 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:35710008.00 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 WITIIIN 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 18 FROM LED 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 3(� granting of this permit. Additionally,the applicant understands and will comply Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9 18. RE-ROOFS: Signature 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 12r)-5 OWNER-BUILDER 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) owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE le6nstruct 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 25505,255 ,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this �i ermit is issued. Owner or authorized agent: Date: 1- / rtify that in the performance of the work for which this permit is issued,I shall r t 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 affirtn 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(See.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`"/ � DateAy GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE- CUPERTINO,CA 95014-3255 4 (408) 771-3228- FAX(403)777-3333-building.0,moetno.gra m 1 ❑PLL7vSTG ❑1` C`r=t�iCkL ❑>:LECTRICAT ❑I'a'sc "IAS-Ous PR OZIrl ADDRESS f-el'r% ,,WR Z/ I F'T J I✓ W `�' STET f>D=- SI Ci i Y,STAT B,ZIP. I i CON ACI'NAd S TPHO:\rE =7✓d�•-� y BOv y,�c Y 'r I 'fo8"-410 /f.Z r Y ��W-e- S-LTIZ %ADDRESS I CITY,STA ' ZI? I FAX 0-'=P, -❑ mm O S.T=t AGS 7 �CO)�4c 08 ❑COAD ACTOP.AC.'.? ❑ c..0=_.CT ❑ C� ❑ D1%0?=e ❑ - F±7 Co\-?'J.CT02?41r?��'d P ©/ � I LiCNSBN Lis � LICE2�SBT?= I BUS.LIC r COIJ�f�QYhdl FAX kNv^ S STIL=E ADDRESS ' CITY,STA'? ZIP KHONE 202 i Gfls ACs/ IAS eglie7`-1 y /vP��e 9yss� ?.2 -,2 zJ��?z .t?2CIv�BCT1c CIl\=E.P.1:�1J� I LiCc.�SE),�UA�u2. I nUS.ISC� . CO),JPf?.TY)\%Al I F.IJ�ATI ( FAX ST=l ADDP.^SS I CITY, ST ZIP I F30\= "USE OF ❑5,—Dr Dmz. i❑ MJLTt-iAtJII Y PROMO N WILDLANJ ❑ YES PP.Ojr.CT IIA ❑YrS IST^BLDG/Im ❑ Y:—:s 3L TL.)T ISG: col^-SP CL"L I IMM t?.II.-IMtrAC AREA NO I -FLOOD ZONE TO I �GTi Eli HOIJ ? ❑ ?O DBSCP.IPTIO)\'OF PdORK -f Po a L IlPw el,1G,/ ooL TOTAT V%ei UAMIO>;: r.n _ By my ti a 1Te Belo a,I C—em:Y to e?-h 0_T Lig follOwLng: I am u,e property ow-,=or authorized agent to act on the prread ihi5 ��alication and the info ariDn I have provided is coreot I have rt--d the Descriptio)of Fork and veru it is ac L'Z-. Mth all€Dplicable local or eLiances L-)d state laws relatLng t0 Lildire col=Uctior. I c`IihL.e orrerreserta:Yes Of Cup---t no to P-Iter the abo-,,, idertmtd proper}'mr L s?em-on DurposeS. ti, A ^1 a R i Date: 9 3 e SI:pa_x:Or r.p_icuv..�.-.::i SUPPLENmNT A 0_Zr01ZMAi10N REQ Li ED -® � NE ME- JklPMY-Tc ap_2D7_7.doc r_vzsed 0612111.1 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21979 SAN FERNANDO DATE: 09/30/2014 REVIEWED BY: MELISSA APN: 357 10 008 BP#: *VALUATION: Iso RIPERMITTYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 RMAP WORK REPLACE E POOL HEATER SAME LOCATION SLIDE POOL SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 1 BAPPLOT 1 # $72 TOTALS: $72.00 R10- i 02 Mech.Plan Check 0.0 hrs $0.00 .l'hrnty. Plan Check 1,&"r(;!re£;% Mech.Permit Fee: IMPERMIT Other Mech.Insp. 0.0 hrs $48.00 Other l'./r,r,z/i Ins p. In PIX?nb,Is£sp..Fee; L c..,..1t 4,' S''_e NOTE.This estimate does not include fees due to other Departments(ie.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the Dept or addn'Z info, FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS Man Check F'ee: SuppL .PC Fee F 17 PME Plan Check: $0.00 P,pl" /isp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Q Administrative Fee: 1.4DM1N. $45.00 Work Without Permit? O Yes O No $0.00 Travel Documentation Fee: 1TRAVDOC $48.00 Strong;Motion Fee: $0.00 Select an Administrative Item Bldg Stds Cormnission Fee: $0.00 A. 19- 0 $213.00 $0.00 TOTAL FEE: $213.00 .. ,..� Revised: 08/20/2014