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15030192CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20343 GILLICK WAY CONTRACTORS tBB T6113E PERMIT NO: 15030192 INE OWNER'S NAME: FABIANO DAVID TRUSTEE DATE ISSUED: 03/31/2015 OWNER'S PHONE: 2096032059 PHONE NO: JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑ LICENSED CONTRACTOR'S DECLARATION INSTALL GAS LINE FOR KITCHEN STOVE License Class Lic.# Contractor Date I hereby affirm that I am licens d 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 J performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $6000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 36936015 00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 DAYS AST CALLED INSP TON. costs, and expenses which may accrue against said City in consequence of the Issued b Dat . Y' granting of this permit. Additionally, the applicant understands and will comply with all no ource regulations per the Cupertino Municipal Code, Section 9 18. _ RE-ROOFS: is Signature- Date All roofs shall be inspected prior to any roofing material being installed. If a roof 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 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, SZw3,and2 534. r� Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date S 7 permit isissued. 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I 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 918. Signature Date aCUPERTINO GENERAL PERMIT APPLICATION 9 -- COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION is 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.oro ❑ PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS MEP MISC PROJECT ADDRESS i. 4� ''j � / % JIC L ► / l 4�7 APN # �� /�1 . ` OWNER NAME{Dy� , ,,P FA 19 t ��// V ` PH� 00 n . ^ -, "• 7 (O E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORN $. 1 gl—s / (• LICEFjI2R LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL[ FAX STREET ADDRESS � I^ iN 's 'G CITY, STATE,ZIPS 9�/ Z J [ P�� E 7< r ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAII, FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD uDUPLEX ❑ MULTI -FAMILY BUIIAING: ❑ COMMERCIAL PROJECT IN WIIALAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK 1 — TOTAL VALUATION: `Qf/REG�IVED B aPNI dam✓ l��w.S Y� h. `R � � f �". .l�.,cG.�x By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on th wner's behalf. I have read this application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with alf applicable local ordinances and state laws relating ding c struction. I authorize representatives of Cupertino to enter the aa-b�ov ide7tid property for inspection purposes. Signature of Applicant/Agent: Date: d SUPPLEMENT ORMATION REQUIRED x "'��' OFFICE [TSE ONLY Oil Rp Sti AVER THE-COU7VTER z: EXPRE$S� '4` yW �c H w y EE, MEPMiscApp_2011.doc revised 06121/11 � CITY OF CUPERTINO �F&R-0l 1VVU T'i 1 CTTM A Tn1P _ RX TTT ,11ING DIVIRION LaiADDRESS: 20343 gillick way DATE: 03/31/2015 REVIEWED BY: Mendez APN: BP#: *VALUATION: $60 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Du lex p 0.0 I PENTAMATION 1 RPGAS USE: PME Plan Check: PERMIT TYPE: i $0.00 WORK install gas line for kitchen stove Permit Fee: $0.00 SCOPE 0.0 I Ifech. Plan ('heck Me& Permit I,'ee: I Other �ilech. Insp. Wech. 1/1"p. Fee: Plumb. Plan Check 1 0.0 1 hrs $0.001 EJec. Plan Check Plumb. Permit Fee: IPPERMIT filet Permit Fee Other Plumb lnsp. 0.0 hrs $48.00 Other k,lec. imp. Pl urtb. Insp. Fee: L lec. hasp. Fee. _r NOTE: This estimate does not includeJees uue to other Departments (tie running, ruoLtc rr vrn�, /'G, Ju/uLu/y JGrvG �LJL. oa y —.I «7.. __ .*:.,, .r /'nntnnt tbo vont fnr aildn'l infn- "fatf LIl9, Lt" . I /L— —a—'. VUJ cas v.. -F. — FEE ITEMS (Fee Resolution 11-053 E . 7fl /1/13) .-. .----.+-.-------------- FEE ------ --- - QTY/FEE - MISC ITEMS Plan Check Fee: $0.00 = # $72.00 Plumbing 1PGASRES Piping, Gas <=4 Outlets Suppl. PC Fee: (E) Reg. ® OT 0.0 I hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. ® OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $48.00 _T_T ConsJruch.on Tax: Administrative Fee: ]ADMIN $45.00 0 Work Without Permit? ® Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0� Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 k 6 $142.50 �� $72.00 x. AIS FEES; $214.50 Revised: 02/14/2UIb