15100108I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 22406 SALEM AVE
OWNER'S NAME: WEST DENNIS L AND BARBARA J
CONTRACTOR: PALO ALTO PLUMBING & PERMIT NO: 15100108
HEATING
716 SAN ANTONIO RD UNIT F DATE ISSUED: 10/14/2015
I OWNER'S PHONE: 4088887458 1 PALO ALTO, CA 94303 1 PHONE NO: (650)856-3400 1
LICENSED CONTRACTOR'S DECLARATION
License Class CLic. #
Contractotb4CC --4C I c-- (� C '-( -w 4 /" Date %4
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:
1. 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
rformance of the work for which this permit is issued.
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
permit is issued.
APPLICANT CERTIFICATION
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this pe it. Additionally, the applicant understands and will comply with
all non -point c regulati spr t e C i nicipal Code, Section 9.18.
Signat Date /G - ,, ' / 5-
1:1
❑ f OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
2. 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
permit is issued.
3. 1 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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
APPLICANT CERTIFICATION
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature
Date
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL (N) GAS LINE FROM METER TO UNIT #2 AND
UNIT #3
Sq. Ft Floor Area: I Valuation: $5000
APN Number: 32615018.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSP CTION.
Issued by:jhqLC&1aW1 Date: fo v'v9,
RE -ROOFS:
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
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Heigh & Safety Bode, Sections 25505, 25533, and 25534.
CONSTRUCTION LENDING AGENCY
I Thereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Add
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professio
GENERAL PERMH T APPLICATION )5100108
COMP✓iUNI —1Y DEVELOPMi�ENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 05014-3255
(408) 777-3228 • FAX (408) 777-3333 - buildino(a-)cuoetL no.org
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LJ 1"ECHA>\'ICAL
LJ ELECTRICAL LJ M'ISCELLAN"EOUS
PROJECT ADDRESS
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C0NTR4CTOR Nal\=
LICENSE NL'ASER LICENSE TYPE
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COMPANY NAIL
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STREET ADDRESS CITY, STATE, ZIP I PHONE
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STREETADDRESS
CITY, STATE, ZIP
1 PHONE
USE OF SFD or DLTLEX ❑ 1,?L LTI-FA \=Y
. PROJECT LN' WILDL.AND ❑ YES
PROrCT LN ❑ YES
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URBA-N I) "FACE ARF4 ❑ NO I
FLOOD ZOME 0 NO
EICHLER HONE?
❑ NO
DESCRIPTION OF WORK
C.0 4 r r
TOTAL VALUATION;
By my signature below, I certify to each of the following: I am the property own ed agent to act on the property owner's behalf. I have read this
application and the information I have pr vid d is correc h read, e Des tion of \r,Torl. and verify it is accurate. I agree to comply N ith all applicable local
ordinances and state laws relating to _ onsu a `'o tho ' repre att of Cup- Ino to enter the above-ideatified property for inspection purposes.
Signal ure of Applicant/?:gent: Date: /D q, /y'
FLEIVENTAI, L\'FORMATION REQUIRED
111' PA17sc 4pp_7011.doc revised 06/21/11
CITY OFUPERTINO
/JI FEE ESTIMATOR CBUILDINDIVISION I�IO�I�
APPLIANCE / EQUIP TYPE
ADDRESS: 22406 Salem Ave
DATE: 10/14/2015
REVIEWED BY: Paul
UNITS
APN: 326 15 018
BP#:
`VALUATION: 1$5,000
PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPGA
PERMIT TYPE:
WORK
Install N Gas Line from Meter to Unit #2 and Unit #3'
SCOPE
Suppl. ksp Fee
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Oec. Permit Fee.-
ee-Other
Piping, Gas >4 Outlets
1 BPGAS
Other Elec. Insp.
1
#
$72
� orinit .Fere:
Suppl. ksp Fee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
("Onsh-uction 1 tzv:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes No
$0.00
TOTALS:
F
Travel Documentation Fee: ITRAVDOC
$72.00
Strom 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. etc.). These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7iU13)
tiech. Plari Check
Plumb. Plan Check 0.0 1 hrs $0.00
1,:1'ec. 1' aii (.'hack
Wech. Pera it Fee:
Plumb. Permit Fee: IPPERMIT
Oec. Permit Fee.-
ee-Other
OtherAleck. 1rup.
Other Plumb Insp. 0.0 hrs $48.00
Other Elec. Insp.
1{ r l lo,!) Fee:
PME Plan Check:
L lec. 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.). These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7iU13)
FEE
QTY/FEE
MISC ITEMS
I' an U] h, �,- (A
Stt�wlP(7 1*'e e
PME Plan Check:
$0.00
� orinit .Fere:
Suppl. ksp Fee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
("Onsh-uction 1 tzv:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes No
$0.00
Travel Documentation Fee: ITRAVDOC
$48.00
Strom Motion Fee: 1BSEISMICR
$0.65
Select an Administrative Item
Bld- Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$214.65
$0.00 TOTAL FEE:
$214.65
Revised: 10/01/2015
RE V EL).5
n T 14
U�t-�z
Bedroom Living Room
BY W orres HFY►TER it
34.5 Bath K Entry 34.5
44
Bedroom }Citchen Dining Ar
RR W1MA4'
UNIT 1*
28.5
28.5
We
Bedroom Living Room
Bath WA
bath0
Bedroom Bedroom L)
--*P - I LL
28 A
.UWMWV
j 31.5 4 4
34 Bath Entry {ST'C&L PIPE
U N
Carport 22
Bedroom Kitchen Dining Area
14
28.5 3':.5 4
2240 (o SALr=m AVE
CUPERTIN10 CA 95014-
7
Storage/Laundry
MET lt-
'BARZRRA WE57' 466.981-0901
Gp�,t(�1' NITY DEVELOPMENT Q �.RTINfOL'N
DENNIS WEST 408 889 74 SS g ILDING DIVISION CU
EMAIL* RAR19ARA 444Yn¢_C0M APPROVED
This set of plans and specifications MUST be kept at the
ake any
ob site during construction. Itis un 1evfuolrt deviate
S �'+ L, E ivl ��% cwt anges or alterations on san
therefrom, without approval from the Building OL IN
OT
The Stamping of this plan and specifications
be held to permit or to be an app
of any visions of any' City Ordirovai of the violation
nance or State Law.
BY
DATE
PERMIT #
CUPERTINO
.
Building Department
UNIT 3*
28 =- -1
OCT 14 2015
Dining Area REVIEWED
FOR CODE COMPLIANCE
Ll N rr ' 3Revie
ed By:
Kitchen Living Room
W)i'1 IC €% 1{FA'TjfSL
�' f'U iCdV 0. ps C i
CLogeT
>be
Entry
Master Bedroom
44
Bath WA
bath0
Bedroom Bedroom L)
--*P - I LL
28 A
.UWMWV
j 31.5 4 4
34 Bath Entry {ST'C&L PIPE
U N
Carport 22
Bedroom Kitchen Dining Area
14
28.5 3':.5 4
2240 (o SALr=m AVE
CUPERTIN10 CA 95014-
7
Storage/Laundry
MET lt-
'BARZRRA WE57' 466.981-0901
Gp�,t(�1' NITY DEVELOPMENT Q �.RTINfOL'N
DENNIS WEST 408 889 74 SS g ILDING DIVISION CU
EMAIL* RAR19ARA 444Yn¢_C0M APPROVED
This set of plans and specifications MUST be kept at the
ake any
ob site during construction. Itis un 1evfuolrt deviate
S �'+ L, E ivl ��% cwt anges or alterations on san
therefrom, without approval from the Building OL IN
OT
The Stamping of this plan and specifications
be held to permit or to be an app
of any visions of any' City Ordirovai of the violation
nance or State Law.
BY
DATE
PERMIT #