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11110018CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21150 HAZELBROOK DR CONTRACTOR: PERMIT NO: 11110018 OWNER'S NAME: DATE ISSUED: 11/032011 OWNER'S PHONE: 4086676493 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # l�Z R -7, r r r MECH RESIDENTIAL COMMERCIAL Contractor Q�L� g.._kS 1„�en�te L—,a - - d I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: SINGLE FAMILY DWELLING ADD NEW FIREPLACE & (commencing with Section 7000) of Division 3 of the Business & Professions BBQ, NEW GAS LINE & OUTLET 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. 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 Sq. Ft Floor Area: Valuation: $12000 permit is issued. APPLICANT CERTIFICATION APN Number: 32655027.00 Occupancy Type: I certify that 1 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non -point source regu ' s er the Cupertino Municipal Code, Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date IL-1 "Zb it Issued by . Date: ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE -ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1, as owner of the property, or my employees with wages as their sole compensation, installed without first obtaining an inspection, I agree to remove all new materials for will do the work, and the structure is not intended or offered for sale (Sec.7044, inspection. Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain Section 3700 of the Labor Code, for the performance of the work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. permit is issued. Additionally, should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued, I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Compensation laws of California. If, after making this certificate of exemption, I Health & Safety Code, Sections 25505, 25533, and 25534. become subject to the Worker's Compensation provisions of the Labor Code,1 must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or autho Date: /� k APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of worVs to building construction, and hereby authorize representatives of this city to enter for which this permit is issued (Sec. 3097, Civ C.) upon the above mentioned property for inspection purposes. (We) agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO FM_7 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 21150 hazelbrook dr. DATE: 11/03/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$12,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: PENTAMATION 1 RMAP1 PERMIT TYPE: WORK sfd add new fireplace and BBQ new gas line and outlet. SCOPE Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Check 0.0 1 hrs $0.00 Elec. Plan Check 1 0.0 1 hrs $0.00 Mech. Permit Fee: IWERMIT Plumb. Permit Fee: 1PPERM/T Elec. Permit Fee: IEPERMIT Other Mech. Insp. 0.0 hrs $44.00 Other Plumb Insp. 0.0 hrs $44.00 Other Elec, Insp. 0.0 hrs $44.00 NOTE: This estimate does not Include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc). These fees are based on the nrelininary information available and are nnly an estimate. Contact the Dent for addn'l info. FEE ITEMS (fee Resolution 11-053 Ef/. 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # $65.00 Mechanical IBAPPLOT7 Other Appliance/Equip Suppl. PC Fee: (F) Reg. Ci OT 0.0 I hrs $0.00 PME Plan Check: $0.00 1 # Plumbing $65.00 IPGASRES Piping, Gas <=4 Outlets Permit Fee: Hourly Only? © Yes 0 No $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 1 7 Electrical $44.00 IBREMIMECEP Recep/Switch/Outlets PME Unit Fee: $0.00 PME Permit Fee: $132.00 Crfnslr;tc.tjo�t Tax Administrative Fee: 1ADMIN $41.00 Q 0 Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 Travel Documentation Fee: 1TRAVDOC $44.00 Strong Motion Fee: 1BSEISMICR $1.20 F-17.07 hrs $130.00 Inspections ISTINSP Inspection, Hourly Bld,v Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $219.20 $304.00 TOTAL FEE: 1 $523.20 Revised: 10/01 /2011