14090199 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21979 SAN FERNANDO AVE CONTRACTOR:CITY OF CUPERTINO PERMIT NO: 14090199
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
REPLACE(E)POOL HEATER,SAME LOCATION(REC
License Class Lic.# POOL
RM)
Contractor Date
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 WORYD
correct.I agree to comply with all city and county ordinances and state laws relating WIT IT ISSUANCE IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
OR
upon the above mentioned property for inspection purposes. (We)agree to save A I 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 compl sue 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
❑
OWNER-BUILDER DECLARATION inspection.
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,
Bus ss&Professions Code)
(6r ner 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,Sections 25505,2W3,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Date: 91
I! it is issued. Owner or authorized agent
rI tify 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 / 70 �
GENERAL PERM11T APPLICATION � NI E P
COMMUNITY DEVELOPMENT DEPART MENl i BUILDING DIVISION (� O
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By my sig,ar're below,I celaiy to each oft following: I am the property ovi•'ner or aLthoni 61 agent i0 act er's behalf. I have read this
application and the info:-:;anon I have provided is col-eat I have read the Description of)%,cork--J-,fry it is zca'�-�te. I z_Tee to Comply With all applicable local
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UPPLEI� 'vT� �0��,�ATION RE U RED
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h,—l'PArisc.4pp_201-7.doc revised 06/21/11
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
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RMAP
USE: PERMIT TYPE:
WORK REPLACE E POOL HEATER SAME LOCATION (REC POOL
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 1 BAPPLOT 1 # $72
TOTALS: $72.00
IR
Mech.Plan Check 0.01 hrs $0.00 1'iatwb. Plait
Mech.PermitFee: IMPERMIT
FT-7
Other Mech.Insp. Tf2!j
01i,er 1'/rrrnb,Irsp. EJrn: P e'c.Irup,
jr€s7. 't'c=: ')'tzli2 J. i?.Sf.1.Fee; !-ec:
NOTE.This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/U131 FEE QTY/FEE MISC ITEMS
Flan Chee=k F'c e:
PME Plan Check: $0.00
Permit T'ee:
Fee
PME Unit Fee: $72.00
PME Permit Fee: $48.00 \
Administrative Fee: IADMIN $45.00 \
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: 1TRAVDOC $48.00
Stroniz Motion Fee: $0.00 Select an Administrative Item
Bldg Stds Commission Fee: $0.00
. .. Ty..., F. $213.00 $0.00 .. , TOTAL FEE: $213.00
Revised: 08/20/2014