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15060050V CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10686 PAR THREE DR CONTRACTOR: NELSON PLUMBING PERMIT NO: 15060050 OWNER'S NAME: SMITH HAROLD D AND LINDA A TRUSTEE 1272 CASTLEMONT AVE DATE ISSUED: 06/05/2015 OWNER'S PHONE: 4087770537 SAN JOSE, CA 95128 PHONE NO: (408)280-5311 aLICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL REPLACE (E) MAIN WATER LINE License Class Lie. # "—go IS Contractor Date I hereby affirm that I am licensed under4he 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 Sq. Ft Floor Area: Valuation: $1200 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by ection 3700 of the Labor Code, for the performance of the work for which this APN Number: 35607046.00 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 WO OT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WIT 180 D + P + T 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 180. LLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses hick may acc a against said City in consequence of the S granting of this erm t. Addition thea licant understands and will comply ssued by: Date: t7 with all non- int so rce regula 'o s per t Cupertino Municipal Code, Section 9 18. C r RE -ROOFS: Signatur Date ,A All roofs shall be inspected prior to any roofing material being installed. If a roof is low 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 ) should I store o handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I e uipment or d 1 s which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by e B Area Air a ty Management District I performance of the work for which this permit is issued. will maintain compliance wit the pertino M ic' al Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the of the work for which this the Health & Safety Code, S ction 5505, 25 3, d 25534. performance Owner or authorized age t: Date: 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255ML CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building6Dcupertino.org M15k; oas-d PLUMBING ❑MECHANICAL F-1 ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS /® 'oe APN n 3 _57 �6 r O OW1dERNAMEQ ` PHONEUt(% /V 655 E-MAIL / /T STREET ADDRESS C , STATE, ZIP/ ® LZ ca FAX CONTACT NAME- P ON ,n?) &7' s EMAIL STATE, P � G�� FAX ❑ O\iwER ❑ ORR�(rFR�-BUA.DER ❑ OWNER AGENT CONTRACTOR ❑'COATIRACTORAGENT ❑ ARCH=CT ❑ ENGBSEER ❑ DEVELOPER ❑ TENANT CONT TU 'A1n LICENS R LICMe T BUS. LIC COMPANTYN 4 C1 4' l [ (+4 m !J�n�v(/h /! r J/�) L PA3C S SS Cas CIT s �S/c P a00 -S f ARCHITEMENGINEER NAME LICENSE NUMBER BUS. LIC n COMPANY DIANE E-MAIL FAX STREET ADDRESS CIIY, STATE, ZIP PHONTE USE OF El SFD or DUPLEX El MULTI-FANULY PROJECT IN WILDLAND EJ YES PROJECT ANE I El YES IS THE BLDG AN ❑YES COMERCIAL BUILDING: ❑ M URBAN B.TrERFACE AREA E] NO FLOOD ZOEl NO EICHLER HOME? ElNO n ^� DESCRIPTION OF WORK • / (e TOTAL VALUATION: goo a r rt a yy By my signature below, I certify to ea of e following: I e p perry owner or authorized to act on the pr net's behalf. I have read this application and the information I h e pro ided is correct. d the Description of Work and verify it is agree to comply with all applicable local ordinances and state laws relatin to buil g constructi �ave I aize representatives of Cupertino to enter a aboove-identified pro e for inspection purposes. Signature of Applicant/Agen . Date:— PLEMENTAL INFORMATION REQUIRED z�'�gy°'��r K- ��. h. NO. � � 1� C.,�� MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO IM, FEE ESTIMATOR — BUILDING DIVISION APPLIANCE / EQUIP TYPE 10686 PAR THREE DR DATE: 06/05/2015 REVIEWED BY: MELISSA IlaADDRESS: APN: 356 07 046 BP#: "VALUATION: 1$1,200 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex # PENTAMATION PERMIT TYPE: 1 RPW d WORK REPLACE E MAIN WATER LINE SCOPE S'zrppl. Insp I'ee APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES /slec. Pernzii Fee: Water Service 1 BPWSVCS Oilier Occ. lnsp. EI-L- 1 # $25 Permit 1%ee: S'zrppl. Insp I'ee PME Unit Fee: $25.00 PME Permit Fee: $48.00 Contraction I,ax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 TOTALS: A Travel Documentation Fee: ITRA VDOC $25.00 Strong Motion Fee: 1BSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, eta). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E{f.' 7/1/13) ;llech. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 lilec:. Plan Check 11 h. t'ennit Fee: Plumb. Permit Fee: IPPERMIT /slec. Pernzii Fee: Other <1 /ech. Insp. Other Plumb Insp. 0.0 �hrs$48.00 Oilier Occ. lnsp. EI-L- Ile(VI. Insp. Pee: Phanb. Iasi). Pee: 11,'1ec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, eta). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E{f.' 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check. Fee: Suphl..l'C' F'ee PME Plan Check: $0.00 Permit 1%ee: S'zrppl. Insp I'ee PME Unit Fee: $25.00 PME Permit Fee: $48.00 Contraction I,ax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fees: A Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission .Fee: IBCBSC $1.00 SUBTOTALS;$167.50 $0.00 TOTAL FEE: $167.50 Revised: 05/07/2015 1: ffNfflffi*y%Mi9%1 COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION CUPERTIN I 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 408) 777-3228 • FAX (408) 777-3333 • building@cuperlino.org COCO 6-0 Owner Name --1 1 + til -MLk- (f ---b Permit No. I a Address (C&s(a ! aL j DK 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. No Go to Question 2. 2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sig_ n bottom of form. V'No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. No Go to Question 4. 4. Is your real property built and available for use or occupancy on or before January 1, 1994? ❑ No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. Please check ONE of the following: RS( My property is a single-family residential real property. See Civil Code Section 1101.4. On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water-conserving'plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the table on the following page. Owner or Owner Agent's Signature: `�� 7U Date: Z— % Upon completing and signing this Certificate, please return it to the Building Division in order to tmal your buuamg permit. SB407 2015.doc revised SOI -1.05/17