15110199CITY OF CUPERTINO BUILDING PERMIT
BUILDING! NORTHCOVE SQ
CONTRACTOR
PERMIT NO: 15110199
OWNER'S NAME GRACIX CARLOS ET AL
W. PI—rCL
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DATE ISSU:11/30/2015
OWNER'S 'P HONE. .408 80203
���F_CA C15,13b
PHONE NO
LICENSED CONTRACTOR'S DECLARATION
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JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
;�
License Class.Lie
REPLACE (E) GAS LINE WITH (N) FOR FURNACE; WATER
HEATER; STOVE AND FIREPLACE
Contiadto'r" Date
yl� rifi',ih'(1!a`.ili,lnse and theprovis' ns of pter 9
d
I her a /!700
(commendng*i , t ti . o , n�: _ O)ofD* ision 3 of the Businch Professions
igejs�fn'iull
Cod6'and f1that miy'' ic f ceand effect.
I her6yv a'ffirffi'u''e'r 'penalty,of Perjury one of the following two declarations:
have: andPi0l.iiiaifitaift;la certificate of consent to self-insure for Worker's
Compensation, as pioVided for b�. Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $3850
performance I . `which this permit is issued.
9f,th'6'-Workifb,r,... , I
. ,
I have and will.- rmuhtam:,Wo,'rker's Compensation Insurance, as provided for by
APN Number: 31641028.00
Occupancy Type:
Section37664ih'e' a'bd1i:!Co 6. for the performance of the work for which this
permit isissue
-APPLICANT CERTIFICATION
I certify that I have'ieadthis application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct.; Lagr6e to:comoly with all city and county ordinances and state laws relating
to building and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon, the &v6mentionedi'pp'erty for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSP CT ON.
indemnify and iceep� harmless, the City of Cupertino against liabilities, judgments,
costs; and expeiises!jIkhich "may `accrue - crue against said City in consequence of the
e7A ^Aff—
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granting of this ddiqonalF ,
Y—ffiry ficant understands and will comply
Issued by Date: I
with all non- int sour 6 egulations per the C ertino Municipal Code, Section
RE-ROOFS:
9.18.;.
I o ks
Signattur: Dater
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.
-71-
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I her Laf rm',that I am exempt from the Contractor's License Law for one of
by'a
/ngtwi)
the fo reasons-
: -
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of th6' propero '
y,,'6r.my:em0loyees 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)`,
1, as ownef:of the�pi6pert y,. am. exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
' _I � , , - ,
construct the project'(Sec.7044, Business & Professions Code).
%,
I have read the hazardous materials requirements under Chapter 6.95 of the
'J': ', , I I
Iff one of the following three
I hereby 4 1
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
Cupertino Code, Chapter 9.12
penalty4 perjury
maintain compliance with the Municipal and the
declaratiofis.—.1"I!,
... , 'i,,' . !,
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have!and1iwii6i�1ai1!1taini it Certificate of Consent to self-insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Com e. ds'p 6Vided for by Section 3700 of the Labor Code, for the
p nsai.ion;� ,
air contaminants as define uality Management District I
;-I
performance of thev�6rk;for,whibh this permit is issued.
will maintain couipli, with the C pe tino Munici ode, Chapter 9.12 and
- P
, .1 . I
I have and will maintain Wdrke,r's Compensation Insurance, as provided for by
the Health & Sa Code, Secti s. 550 25533, and 25 4.
. 'llo, (;.l: , I t
Section 3700,iof the,Labof CcIaJbr the performance of the work for which this
Date:
permit i d
sJssup, i'• Iia
Owner or authors agen
performance
th'at-in the peffonnahc6 of the work for which this permit is issued, I shall
I certify, ..
1.. . I I . i- I .: l I s;,, ;.
not employ. ainy'p. person i'n' any manner, so as to become subject to the Worker's
'I .. i -D
Compensation laWs !of California.'f�i�iia: If, �after making this certificate of exemption, I
S4U TION LENDING AGENCY
b Me '�W&keils� Compensation provisions of the Labor Code, I must
eco 9u1'jd`ci.io,1he'
I hereby affirm t hatthere isaUoniruction lending agency for the performance of
forth,w'i'th'q'om'p'l�'y',:w"ith such provisions or this permit be deemed revoked.
work's for which this 'permit i i ued (See. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify.that I hiV6-f6ad,this� application and state that the above information is
;
coect. I agree ,td,coi ; u I p
rr ly'wfth ail city and county ordinances and state laws relating
to building constructiori,'�nd6re6y authorize representatives of this city to enter
1j 1j,; , 1, "'.. '. f inspection purposes. (We) agree to save
upon! the,ap.. Pyementi6ned property, or
indeinn'ify':andke�e' "h'' :�`46��'ihet_ity'of Cupertino against liabilities, judgments,
p4M .. .,�
ARCHITECT'S DECLARATION
, . 1,
cost�;iand'e'xpe''n'ses',�w'h"ch may,accrue against said City in consequence of the
... I': ", 1
I understand my plans shall be used as public records.
nig
granting of this permit. Additionally,' the applicant understands and will comply
with all non-poi'n:t.so'u"rce.r'egulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTIN
GENERAL PERMIT APPLICATION 1511® lqq
COMMUNITY DEVELOPh4EN T DEPARTMENT -BUILDING DIVISION
10300 T ORRE AVENUE - CUPERTINO, CA 85014-3255
(408) 777-3228 - FAX (4-08) 777-3333 • buildinciO)CUDeitno.Org
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DESCRIPTION OF WORK
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TOTA-LW- UAT?ON:
By my siQaat n -e below, I ce-ify to each of the following:
I an the propefty owner or authorized aeeat to act on the propery owner's behalf. I have rezc
application and the L-ifonnation I h -N-9 provided is correct.
I have read the Desc,iption of )Work and verify itis accurate. I agree tR comply N i -:h all applic
ordt-ances and state laws relat, g t " u ]ding construction.
I zu Jorge representatives of Cupertino to enter he zbo e--ipi ie ;y for inspection I
Signa ure of A.pp'_iczn / A went:
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Date:
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h�FPh!isc.�vp 2011.doc regi.
CITY OF CUPERTINO
FFF FCTIMATOR — RTTILDING DIVISION ` I
ech f'l ara C''1's� -
r;Alech X'i r -r lite;
thne, i%1L'cU?.'.6? Vii.
ADDRESS: 20212 Northcove Square
DATE: 11/30/2015
REVIEWED BY: PAUL
FEE ITEMS (Fee .Resolution IL -053E, . 71,11.13)
APN::.316.41028
BP#:
*VALUATION: 1$3,850
PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY,
USE: ' S ' Dor Duplex
PENTAMATION
PERMIT TYPE: 1 RPGA A
WORK.'
Re lace E as line with N for furnace; water heater; stove and fireplace
SCOPE:
$0.00
ech f'l ara C''1's� -
r;Alech X'i r -r lite;
thne, i%1L'cU?.'.6? Vii.
Plumb. Plan Check 1 0.0 1 hrs $0.00
Plumb. Permit Fee: IPPERAffT
Other Plumb Insp.0.0 hrs $48.00
I'ha? ib.Imt;, Fee:
f le<;..!'Itrr. Cheri;
1s?ec..f'ernaii F. -e:
t:)fhe>Lj
Elec. bi.S'p. Fee:
NOTE: ,This estimate;does not include fees due to other Departments (i.a Planning, Public Works, Fire, Sanitary Sewer District, School
District, eiL). 'These ees are based on the Prelimina information available and are only an estimate- Contact the De t or addn'l info.
FEE ITEMS (Fee .Resolution IL -053E, . 71,11.13)
FEE
QTY/FEE
MISC ITEMS
`Pl}an: Check:
$0.00
jPMEt
l' '.Msj!i -e. e
PW Unit; Fee:
$72.00
PME'Permit Feer
$48.00
�:,'E1f�TS%1?tdC'lICJYI' �C�1�' '
i
�ldmiriistrative Feb: ]ADMIN
$45.00
'Work Without Permit? 0 Yes No
$0.00
11.16dn�cd,P1dnh1,1 Fees:
Travel- Documenfati,on Fee: I TRAVDOC
$48.00
Stiong: iohTee:' IBSEISMICR
$0.50
Select an Administrative Item
IBCBSC $1.00
TOTALS: $214.50
$0.00
10/01/2015