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14100198 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21831 LOMITA AVE CONTRACTOP444P--+&BE PERMIT NO: 14100198 TMTMCMI MED OWNER'S NAME: 1 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL + REPAIR WATER MAIN License Class Lica+# 6 8`i Contractor P(UINnb 0n— C• Date lO 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:$4400 have and will maintain Worker's Compensation Insurance,as provided for by tion 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35r L11 145.0® Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT E7AYS RK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 1RMIT 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 ALLED INSPECTI N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Igranting of this permit. Additionally,the applicant understands and will comply Issued by: Date: U k, with all non-point source regulations per the Cupertino Municipal Code,Section 9 18. t j RE-ROOFS: 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 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 - C=NEP.AL PERMIT RaFLICA i IONMEP irCOMMUNITY DEVELOPMENT DEPAP.i IJiLNT BUILDING DIVISIGi. �(,� i 10300 T ORRE AVENUE- CUPERTIND, CA°5014-3255 V (� ('08) 777-3228.1=rX(!06)7777-3333•building® :uDe lno.oro. I MIS (; EIJ��+I�IO I� L 7-111rim-TG11,TC`rQiiCAL DE-, T �1\1JCP_L.AY_POUS raaa,ADS?.as5 ��s�3 i ,�;�-� �� . � ��i;r • G n��h k 1,�• + CO?�?ACT hki,r. �+` ��✓��?30h q p--1 C,�I =7✓4� �� eq &&, S;L- —DD--l2S CTY,STAT u? c owc ❑ 0v,-p—.,=u'',m ❑ ow---,A 1z ❑ Co\-:?-4C:OiZ ❑COh SCTORAC.Z ❑ ��C_=QCT ❑TGv? ❑ D1 ?� ❑ =��T BUS.LiC Y� Ta£� GA 15-1(Z I i o. �c�;ycTr_?cn.—teais�1 I Tic--KE-Ziq,-11SwR. Imus: CG2JDf�dYA'.A7� I I✓iAII. •I F!.i fi7? T hDDP SS I CTY,STAT2�=P TSSB OF ❑-rD r,D%J?LE: !-❑ )zm-,7-F u.ID..Y I MO=CT N.w=LAXID D YES I FROM CT N, Yss I isi_BLDG AN ❑ Y S 3LLTJneG: COiJ �CLSL iiu3t?T sAC=�3aA. ?'O :r.00D?o? ❑TO =iC�u a01�1 ❑ ?O DMCFUMION Or'ROOK tow TOTE r V e r UAi'IO~;: Q'b ��.,�=� �-�� - �5.�� _• �V IDp ci gt„-e�e1C\i',I Ce �'io E3^.h 0-T t�'Se i011o\i'i'i: I aIn the property ow-er or auffimiz.d agent`•o act O, 0\i•Teei'S hel:al' I h ve ead application and the ir:o:—adon I have prof idcd is co-crt I have-__d the Desci iption of F,`ork and cel_f;it is zcclZMe i e=et to co-�ply arch,all_pli—ble local O:dimmces and at-_,e l_,4'S relating t0 ml ,H consmumnon. I wunhor•_'ren-esenianves of Cupw,no to.'rater Lie �.cd LS�ec-lon pU?rposes. Si_-tare ofA�alic_,t'=_=ens. r µ` )ate: t� I� `T, QTJ RON IWag— WO • � ;+=cam, ��-�, �"��, • � .rte°'�� _ .� .M1 _�:Il•SC.!/7�7VI LGOC revise 06/-21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21831 lomita ave DATE: 10/30/2014 REVIEWED BY: Mendez APN: BP#: "VALUATION: 1$4,400 xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPW USE: PERMIT TYPE: WORK re air water main SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Service 1BPWSVCS 1 # $25 TOTALS: $25.00 .Ta Pa it- M Plumb.Plan Check 0.0 1 hrs $0.00 L9: ;'. 1'>rrn{tF'ee: Plumb.Permit Fee: IPPERMIT 1 �rr- r r 0'6,, r lI(<A rr,,,,P. Other Plumb Insp. 0.0hrs $48.00 ()oyez.ieic, 1>sp>. We9 , a hvsv)_ t est flherid), insp. Fee: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on th,e relimina information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (Fee Resolution 11-053 Eff.711/131 FEE QTY/FEE MISC ITEMS Plan Ch(a(,k Fee: PME Plan Check: $0.00 E.r ,., TrZit 'tT` :S'q)?l. rr'7.g/?Pee PME Unit Fee: $25.00 PME Permit Fee: $48.00 cr'onsij uction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 ic.i U11("Cr!. 11/"trm ing Fc"'es: Travel Documentation Fee: ITRA VDOC $48.00 Strom Motion Fee: IBSEISMICR $0.57 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $167.57 $0.00 u_ FEE- $167.57 Revised: 08/20/2014