12100055 CITY OF CUPERTINO BUILDING PERMIT
13111 LDING ADDRESS: 21230 110M1iST EAD RD CONT'RACT'OR:AQUATEK PLUMBING INC PERMIT NO: 12100055
OWNER'SNApIF,: VILLAGE GREEN ASSOCIATE'S PO BOX 23271 DATE ISSUED: 10/092012
OWNER'S PI IONS: 4082942924 SAN.IOSF.,CA 95153 PRONE NO:(408)29s-7767
LICENSED CONTRACTOR'S(DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUNIB r
License Class C-S Lic.4 ()-- 1 S' 1 r r r-7D1ECF1 RESIDENTIAL CODIM ERCIAL
Contractor cv L.• Date to -Cx • Ii-1— -
hereby affirm that 1 am licensed under the provisions of Chapter'), JOB DESCRIPTION:APTII I-114-E6IERGENCY GAS LINE(PRESSURE TEST
(commencing with Section 7000)of Division 3 of the Business& Professions DUE
Code and that my license is in full force and effect. TO FIRE)
hereby affirm under penally of perjury one of the fallowing 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 die work for which this Sq. Ft Ploor Area: Valuation:$500
permit is issued.
APPLICA\rCERT'IFICAT'ION AI;N Number:32605085.00 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 Imes relining
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may secure against said City in consequence of the
granting of this lit. Additionally,the applicant undcrst.•mds and will comply
�S . J 180 1) YS FROM AST CALLED INSPECTION.
with all no� int source regulatims per the Cupertino Municipal Codc,Section
9.18.
! g
Issued by: O V Dale:
Signature Date
vr� i i
13RN
OF -13UIL�R DF PION
Rb:ROOFS:
hereby aMrm that 1 am exempt from the Con uCar(or's License La I% fur one of All roofs shall be inspected prior to any roofing material beitg installed.If roof is
the following two reasons: installed without fust obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR RETT'F.R
hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self insure for Worker's RA7.ARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this pemtit is issued. California Ilealth&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work Torr which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bav Area Air Quality Management District I mill
I certify that in the performance of die work for which this permit is issued,I shall ma intain1,rnplianEe wi h the Cupertino Jlunicipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilcalth�&S.afety Code.lc- ns 25505,25533,and 25534.
Compensation laws of California. If,alter making this certificate of exemption,I (\ X
become subject to the Worker's Compensation provisions of Labor Code,I must V"�Cgr a t /tged llgetlt V �O .� • 12
forthwith comply with such provisions or this permit shall be deemed revoked. t
V Date:
APPLICANT CERTIFICATION CONSrRRCITON LENDING AGENCY
I certify that I have read this application and state that the above infommlion is I hereby affirm that there is a consimetion lending agency for the performance of swrk's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of
granting of this permit.Additionally,the applicant understands and will comply ARCI I ITECI"S DECLARATION
with all non-point source regulations per the Cupenino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
12 1 '--) Ql:>c--� -:5s
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 RAI A
CUPERTINO�( (408)777-3228 • FAX(408)777-3333 • buildincOCUDDedi�no.o—ro '\v/' v\
L/J PLUABAIG ❑NLCHA.*IICAL ❑ELECTR]CAL /—❑MISCELLA: OUS
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PROJECTADDRESS (�I y APNp
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ST—1-ITADDRESSCTTY,STATE I'? FAX
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❑ OwN ❑ OWN -BUDDER ❑ OWNER ACTT I PCON'TRACiOR ❑CONTRACTOR AG:]+T ❑ ARCF�r ❑ENGIEFR Cl OEV PER ❑ TENANT
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COMPANY NAME' E-MAD. FAX
STREET ADDRESS I CIT Y,STATE,ZIP PHONE
USE OF o s m OUPt CY '�MULTIFAMD.Y PROJECT N WD.DLAND O Yrs I PROJECTIN ❑ YES I M THE BLDG AN ❑ YES
BUTLDNG: COWERCW. URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESC ,ON OF WORK
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TOTAL VALUATION: �Q I RECEncD BY:
By my signat below,I eetufy to each of the.cllowing: I am the pmpery owner or authorized agent m as on the property owner's behalf. I have:-ad;his
application and the huomation I have provided is co,-m I ItaveT:ad the Descaption.of*ork and verify it is accurate. I agree a comply with all applicable local
ordinair_s and sate taws relating,to`onilding consnucdoa. 1 anze,;�eptes�el`an{a of Cupertino to enter the above-idmti5ed p:opey for inspection put�joses.
Signa.Tsof Apnli=t1AgeaCCiV\rr�� Data.
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�L�LEI,EN A.L INFORMAI4ON IZEQUIREL� OFFICE USE ONLY
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OVER-THE-COUNTER
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❑ MAJOR
.&CF.kfucApp_2011.dot revised 06/21/11 -
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21230 HOMESTEAD ROAD DATE: 10/09/2012 REVIEWED BY: LARRYS
APN: BP#: 'VALUATION: $500
*PERMIT TYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY Multi-Family Dwelling Buildino is PENTAMATION 1RPGAS
USE: 3 Stories O Yes (F) No PERMITTI'PE:
WORK EMERGENCY GAS LINE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1PGASRES 1 # $67
TOTALS: F $67.00
Alech.Plan Check Plumb. Plan Check 0.0 hrs $0.00 Flea Plan Check
Alech.Permit Fee: Plumb. Permit Fee: IPPERMIT Elec.Permh Fee:
Other Afech./avp. Other Plumb Insp. 0.0 hrs $45.00 Other Elco.Insp.
E17-
Me&bop. Fee: Plumb. btcp. Fra: Elce.Insp.Fee:
NOTE: This avdinate does not includejeav clue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . These feev are based on the Prelitninan information available and are ontr an estimate. Contact the Dept for addn'I info.
FEE ITEMS (Fee Revolution 11-053 Eff MLI J/ FEE QTY/FEE MISC ITEMS
Plan Check Fee:
SuppL PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. lisp Fee
PME Unit Fee: $67.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: MDMIX $42.00
Work Without Permit? 0 Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITR,u'DOC $45.00
A
Strone Motion Fee: IBSFISMICR $0.50 Select an Administrative Item
131cig Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $200.50 $0.001TOTAL FEE: $200.50
Revised: 10/01/2012