15120118CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21821 ALCAZAR AVE
CONTRACTOR: ALLSTAR PLUMBING
PERMIT NO: 15120118
OWNER'S NAME: GIDCUMB JANICE P TRUSTEE
326 PHELAN AVE
DATE ISSUED: 12/14/2015
OWNER'S PHONE: 8312148561
SAN JOSE, CA 95122
PHONE NO: (408) 230-5569
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑
RE -PIPE (E) BANCH FROM KITCHEN TO MAIN
AIF License Clas �2 1 l
`�
Contractor -- . I lL Date -2 -L 1�
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:
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: $2100
rformance of the work for which this permit is issued.
jt
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
APN Number: 35715065.00
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 WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF IT 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 DAYS F -S- ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
1i
granting of this permit. Additionally, the applicant understands and will comply
with all non -point sourc regulatio "per the Cupertino Municipal Code, Se
RE -ROOFS:
9.18.
"S
Signature Dat t 2,_14
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.
❑ 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. 1 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 pen -nit 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
Section 3700 of the Labor Code, for the performance of the work for which this
the Health & Safety Code, Sections 255 , 25533, and 2 4.
Owner or authorized agent 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 malting 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
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
9.18.
Signature Date
GENERAL PERMIT APPLICATIONMEP
f
COMMiiUNITY DEVELOPA/iENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 9501!-3255
(408) 777-3228 • FAX (408) 777-3333 • buildino(a (
C LI P E RT E t�I 0', cuoertino.orq sl 00// s
M I
] PLU1,/13ING [:1 NECKANICAL ❑ ELECIRICA.L ❑ bruSCELLAN OUS
PROIF.CT.A.DDPBSS APN'
OWNER NA lJ � ` PH
CU I � 3 2-tl
I E-I✓iA.tZ
VV_k1 - cs
STREET ADDRESS CITY} S
I FAX
COITTACT N.k-va � PHO
I E-NLk%
STR ET ADDRESS
CITY, STATS, ZIP
I FAX
❑ ❑ OW=N—.-BUTu7E-Pt ❑ Ovn,-rM:,G-.'T ❑ Co\r,7"%CTOR ❑ CON7RSCTORAG?iT ❑ ARCFETECT ❑ EN-GW—EER ❑ D-7�7ELOP R ❑ E? F�7
CONTRACTOR N.A.1,E I LICENSE 1SUh43ER I
I LICENSE i �YL
BUS. LIC
COIJ .kxy )�
E-N-AiL
FAX
�f
STREET ADDRESS n
'&
CITY, STATE, ZIP
PHONE
�� , � O
r-.
FRCHITECTrnGELKEER NAME
LICENSE NU1,4BER
BUS. LIC
C0I✓2A—N Y K JvE
E -N,.` m
I FAY
STREET.ADDRESS
CITY, STATE, ZIP
I PHONE
USE OF ❑ SFD or DUPLEX muLTI-FAI,f1LY EliL
YES PROCT AI
❑ YFS
IS THE BLDG.AX ❑ =s
BU-IDNIG: ❑COI,C,E:PCI4L j.PROjECTI2N'WILDLA-\7D
uRB!YL>\'T- ACEARE0. '0 FLOOD WKS
-9--,\0
EICHLERHOIJB? f�jip
DESCRIPTIO?\ OF WORK
P �Lof cos t -o d -ed r-, ,1 y a��
EA
r
TOTAL VALUATION:
By my signatue below, Ice~iii to each of the f owing: Ian the property owner or aur ed age Lo act on.t
ner s behalf. lhaveread7to51
application and the izfornation I have pmvid i correct. I have read the Description of \ - IL accurate. I agree to comply with all applicable loci -
ordinances and state lag's relating t uil " co su tion. I authorize representatives of Cupertino to enter the above -identified propel ty for inspectionrp
puoses.
Siq:n= e of pplicaDVAgent: ✓ Date: I-- h —
SL�'t �i�� 1 AI. Lr\r ORvI,4TI01\ REQULp.ED
:'OF1 �C_ELSEOI1:`r. xn x:t:.
s
=
57-
R ,
OVE1 Tim COii ��PR3i. �Y Mi
ti
�'
tl,2EPh!isc.4vp_?01].doe remised 06121/11
CITY OF CUPERTINO
W�_wff FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21821 ALCAZAR AVE
DATE: 12/14/2015
REVIEWED BY: MELISSA
APN: 35715 065
1 BP#:
.*VALUATION: 1$2,100
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
Heuh,
PENTAMATION IRPRP
PERMIT TYPE: A
WORK
RE -PIPE (E) BANCH FROM KITCHEN TO MAIN
SCOPE
Perinil.b,'ee:
APPLIANCE / EQUIP TYPE
FEE ID
Eier_ Pion
QTY
UNITS
BP FEES
Re -Pipe Interior
1PRREPIPE
Heuh,
1
#
$14
Perinil.b,'ee:
S'Ujy)1' 1nsp.F(-'!e
PNM Unit Fee:
$14.00
PME Permit Fee:
$48.00
, nsiruclion TqX.-
"0 —T-1
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
Travel Documentation Fee: I TRA VDOC
$14.0
Strong Motion Fee: IBSEISMICR
Afech. lllftn
Plumb. Plan Check 1 0.0 1 hrs $0.00
Eier_ Pion
MISC ITEMS
Plumb. Permit Fee: IPPERMIT
i'lec, J'erlt'41 Fee:
Other Plumb Insp. 0.0 hrs $48.00
0t,`Ier filslo.
Heuh,
h,1ca Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, P ire, Sanitary Newer utstrici, ycnoot
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the DeptJor aaan'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711173)
FEE
QTY/FEE
MISC ITEMS
phin
Sul
PME Plan Check:
$0.00
Perinil.b,'ee:
S'Ujy)1' 1nsp.F(-'!e
PNM Unit Fee:
$14.00
PME Permit Fee:
$48.00
, nsiruclion TqX.-
"0 —T-1
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
Travel Documentation Fee: I TRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: I BCBS C
$1.001
SUBTOTALS
$156.501
$0.0 FEE:
1 $156.501
Revised: 10/01/.2015