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15040003-EXPIREDV-( CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10457 S DE ANZA BLVD CONTRACTOR: FRESNO PLUMBING & PERMIT NO: 15040003 HEATING, INC OWNER'S NAME: DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL E] 10457-10497- INSTALL 6" FIRE LINE FOR BLDG C — 3� License Class Lie. # 7Z 4 srz-. SPRINKLER, RP DEVICE; POST INDICATOR Contractor�� � Date '412 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $20000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35917019.10457 Occupancy'I'ype: 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 PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 18 I D ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter YS FR SPECTI N. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, , I costs, and expenses which may accrue against said City in consequence of the sued by: Date: 7 Z granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the C rtino Municipal Code, Section 9.18. 2 RE -ROOFS: installed. If is Signature All roofs shall be inspected prior to any roofing material being a roof 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, 255339 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(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 permit 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 the Health & Safety Code, Secti 5505, 25533, and 5534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: 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 CONSTRUCTION LENDING AGENCY 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 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 1 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 CITY OF CUPERTINO ICY/�I FEE ESTIMATOR — BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School D' Th ---A -don the relimina information available and are onlv an estimate. Contact the De t or addn'l in o. istriet, etc.. ese er FEE ITEMS (Fee Resolution 11-053 Eff 711,13) ADDRESS: 10457 s de anza blvd DATE: 04/01/2015 REVIEWED BY: Mendez tr �t� :', APN: BP#: 1 q060_3 'VALUATION: 1$20,000 -PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY USE: Commercial Building Civil / Religious activities in BQ zone? © Yes o No PENTAMATION 1 GENCOM PERMIT TYPE: i WORK 10457-10497- install 6" fire line for bldq sprinkler, rp device post indicator SCOPE NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School D' Th ---A -don the relimina information available and are onlv an estimate. Contact the De t or addn'l in o. istriet, etc.. ese er FEE ITEMS (Fee Resolution 11-053 Eff 711,13) FEE "bunh. Plan ("'heck FT Elec. Plan Check tr �t� :', 1'lumr"i Elec. Permit Tee Other ;1 &L.h. Insp fm Ivr 1'lumb Insp. Ej Other Elec. Insp. Aleeh. Insp. Fee: t'izunb, hrcp. Lac: L:4c( [,err>, V" NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School D' Th ---A -don the relimina information available and are onlv an estimate. Contact the De t or addn'l in o. istriet, etc.. ese er FEE ITEMS (Fee Resolution 11-053 Eff 711,13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Yes Q No $0.00 2 1 hours $286.00 Plan Check, Hourly 1STPLNCK Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ()Yes Q No $0.00 Suppl. Insp. Fee -.0 Reg. Q OT 0. hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXC $0.00 Idininistrative Fce: 0 Work Without Permit? Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential E) Building or Structure 0 A 1'ravel Doc°umenlation Fees: Strony- Motion Fee: IBSEISMICO $5.60 2.0 hrs $286.00 Inspections ISTINSP Inspection, Hourly Bldg_Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $6.60 $572.00 TOTAL FEE: $578.60 Revised: 02/14/2015