15100225CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 867 FERNGROVE DR CONTRACTOR: VALLEY HEATING & PERMIT NO: 15100225
COOLING
I OWNER'S NAME: MOORE JOHN C AND CATHERINE K 11171 N 4TH ST I DATE ISSUED: 10/28/2015 1
OWNER'S PHONE: 4082194499
LSF_ LICENSED CONTRACTOR'S DECLA�R(ATION
License Class L 2� Lie.#
Contractor 7' Date j t1� 2 STT
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
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.
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 A�,-Z-- Date l Ul2 rx^
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt 1'rom the Contractor's License Law for one of
the following two reasons:
1 1, 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:
t. 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. 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
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
SAN JOSE, CA 95112 1 PHONE NO: (408)294-6290
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL (N) WATER HEATER, SAME LOCATION
Sq. Ft Floor Area: I Valuation: $1900
APN Number: 37539048.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date: 10 1 'Z 0
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. 1 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
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner authorized aunt:21, Date:
CONSTRUCTION LENDING AGENCY
I hereby 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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTIr40
GENERAL PERCMI i APPLICATION 151 CCaD9�5
COMMUNITY DEVELOPId�ENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildina(G)CUDeriino.OTQ
PLUMBING
ELECTRICAL
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USE OFFD or DUPLEX [31✓,ULTI-FA L-1MY PROJECT IN WILDLAND YES ?RTcIN
OCT ❑ YES
BLTaBNO: ❑ Cohn jMCLAI URBAN: LNTERFACE AREA 1\10 I FLOOD ZONE NO
IS THE BLDG AN El Y=S
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DESCPJPTION OF WORK �n
TOTAL Vp LUATION: ' L ')0 L
By my signature below, I certify to each of the followime: I zn the property o;;"mer or authorized meat to act on the ope.-ty owner'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;vith all applicable local
ordinances and state laws relatir-g to ding construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Sismah:reofApplicant/Agent: Date:
SU-PPLEhfENTAL IN'F'ORMATION REQUIRED
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A11'EP_A-flscApp_2011.doc remised 06121/11
CITY OFUPERTINO
FEE ESTIMATOR CBUILDING DIVISION 19C0995
191
ADDRESS. 867 Ferngrove Dr
Muazh. flan Check,
DATE: 10/28/2015
REVIEWED BY: PAUL
BP FEES
APN: 375 39 048
BP#:
1 PRWHEATR
*VALUATION: j$1,900
*PERMIT TYPE: Minor Building Permit
PLAN CHECK TYPE: Water Heater
PRIMARY SFD or Duplex
USE:
'e,rmit Fee:
PENTAMATION PRWHEATR
I PERMIT TYPE:
WORK
Install N Water Heater Same location
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
Muazh. flan Check,
QTY
1lech. Perinir 1 -'
BP FEES
Elec_ I'<rr reit FCC.
Water HeaterNent Unit Fee:
1 PRWHEATR
Other Elec. Insp.
1
1'himb. Insp. Fee-
$29
'e,rmit Fee:
SuppL Insp Fec
PME Unit Fee:
$29.00
PME Permit Fee:
$48.00
_'onstruction Tax:
4(lministrt,71h,e Fee:
Work Without Permit? O Yes O No
$0.00
.,/chanced .Planning Fees:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Molion f'ee:
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 only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-033 Eff. 711113,
lech, Plan Check
Muazh. flan Check,
Elec. flan Check
1lech. Perinir 1 -'
Plumb. Permit Fee: IPPERMIT
Elec_ I'<rr reit FCC.
/thee AIech. Insp.
Other Plurnh .Irusp. $48.00
Other Elec. Insp.
Ifech. Insp. Fee:
1'himb. Insp. Fee-
Flee lnsp. 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 only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-033 Eff. 711113,
FEE
QTY/FEE
MISC ITEMS
Phin Check Feer:
S'uppl, N..' Fee
himh.lAkch.%Elec
'e,rmit Fee:
SuppL Insp Fec
PME Unit Fee:
$29.00
PME Permit Fee:
$48.00
_'onstruction Tax:
4(lministrt,71h,e Fee:
Work Without Permit? O Yes O No
$0.00
.,/chanced .Planning Fees:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Molion f'ee:
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$126.001
$0.00 TOTAL FEE: T
$126.00
Revised: 10/01/2015