160100080
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10991 N DE ANZA BLVD
CONTRACTOR: AMERICAN PERMIT NO: 16010008
RESIDENTIAL SERVICES OF CA
OWNER'S NAME: OYAMA LEO TRUSTEE
965 RIDGE LAKE BLVD STE 201 DATE ISSUED: 01/04/2016
OWNER'S PHONE: 4085985108
MEMPHIS, TN 38120 PHONE NO: (408) 982-0405
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
ff _
STAR ONE CREDIT UNION -REPLACE (E) WATER
License Clas,C3(� ;.�'` �i2 Lic. # '� S'i SS
HEATER,
{�. ,r� . d
Contract�c��1`i'��1�GLlr`�SI Date'' l
SAME SIZE & LOCATION
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
performance of the work for which this permit is issued.
rave 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: 32610059.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRE IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WI 6yS OF P 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
AYS FRD INSPECT N.
indemnify and keep harmless the City of Cupertino against liabilities, judgment
costs, and expenses which may accrue against said City in consequence of e
d
granting of this permit. Additionally, the applicant understands and will comply
Issue y: Date: (s
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
�
RE -ROOFS:
Signatur Datc/"
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
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)
1, 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(x) 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 permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapt&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, SeS6ns 25505, 25533, and 25534.
/ , , / .
Owner t:
permit is issued.
or authorized a e a„tt
g V
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, 1
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a constriction 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 APPLICATIONMEP
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 T ORRE AVENUE • CUPER T INO, CA 95014 3255
(408) 777-3228 • FAX (4-.08) 777-3333 • building CUDerino.orq
CUPERTIt-40. �60
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By my signature below, I certify to each of the following: I am the -oroperty owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is co.—, ect. I have read the Description of )Work and
verify it is accurate. I agree to comply,t:ith all applicable local
ordinances and smote la ,,s relzti.-/g to building constr.Llction. I authorize representatives of Cupertino
to enter the above -identified property for inspection purposes.
Signature of."-.pplicant/Agent /
Date: CDT ( C -*4 /
SUPPLEMENTAL W ORIMATIOIT REQULRED
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h EPM,"isc,vp_2011.doc remised 06/21/11
CITY OF CUPERTINO
rm—R—W FVF. VRTINFATOR — RITILDING DIVISION
ADDRESS: 10991 N DE ANZA BLVD
FEE ID
DATE: 01/64/2016
REVIEWED BY: MELISSA
APN: 32610 059
BP#:
A
EVALUATION: 1$2,100
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
Commercial Building
USE:
#
$29
PENTAMATION
I PERMIT TYPE: PCWHEATR
WORK
STAR ONE CREDIT UNION - REPLACE (E) WATER HEATER, SAME SIZE & LOCATION
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
A
Water Heater .
1PCWFiEATR
1
#
$29
TOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, lire, sanitary sewer District, school
District, etc). These.fees are based on the preliminary information available and are only an estimate. contact tete uept,fora(tan-iinjo
FEE ITEMS (Fee Resolution .1.1-053 LL7103)
FEE
QTY/FEE
MISC ITEMS
A
PME Plan Check:
$0.00
P""Iwfi/ FCC:
PME Unit Fee:
$29.00
PME Permit Fee:
$48.00
Administrative Fee: JADMIN
$45.00
Work Without Permit? C) Yes 0 No
$0.00
Ad "ces:
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: IBSEISMICO
$0.59
Select an Administrative Item
Std Stds Commission Fee. IBCBSC
$1.00
SUBTOTALS - '
$171.59
.....
$0.0q ,TOTAL FE
171.59
Revised: 10/01/2015