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11060039 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20659 SHELLY DR CONTRACTOR:SQUARCIA LARRY G AND PERMIT NO: 11060039 YOLANDA OWNER'S NAME: SQUARCIA LARRY G AND YOLANDA 20659 SHELLY DR DATE ISSUED:06/06/2011 l sR'S PHONE: 4083147575 CUPERTINO CA, 95014-2923 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:ADD WHOLEHOUSE WATER FILTER/SOFTENER;UNIT I hereby affirm that I am licensed under the provisions of Chapter 9 MOUNTED (commencing with Section 7000)of Division 3 of the Business&Professions IN GARAGE,1 INCH COPPER WATER PIPE 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. 1 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:$4100 permit is issued. APPLICANT CERTIFICATION APN Number:35911024.00 Occupancy Type: 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 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 accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. /ze, Issued by:--- -� Date: C� Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,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, Signature of Applicant: Date: Business&Professions Code) 1,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 BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I 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& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Heal &Safety Code,Secti s 25505,25533,and 25534. 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 Ow er hoc' a r� Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work'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 -nnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address ,,and expenses which may accrue against said City in consequence of the granting of tlyis permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non Cupert oint source regulations per ino Municipal Code,Section 9.18. [understand my plans shall be used as public records. Signatur Date ,( Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION JAPN: DDRESS: 20659 shelly dr DATE: 06/06/2011 REVIEWED BY: larry s BP#: 'VALUATION: 1$4,100 'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY 7-SFD or Du lex PENTAMATION 1 RPWP USE: p PERMIT TYPE: WORK add wholehouse water filter/softener. unit mounted in garage, 1 inch copper water pipe SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Water Treatment 1PREPPIPE 1 # $42 TOTALS: $42.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.00 NOTE: These -fees are based on the preliminary information available and are only an estimate. Contact the De ptfor addn'1 in o. FEE ITEMS (Fee resolution 09-051 EJ: 7/1/10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $42.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes G No $0.00 Travel Documentation Fee: ITPA VDOC $42.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item I31d Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.501 $0.00 TOTAL FEE: $127.50 Revised: 04/29/2011 I t C6 �00o:,3r, GENERAL PERMIT APPLICATION _ MEP COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333-buildingCacupertino.org MISC CUPERTINO PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 2-0 6S--9 sWG-"L!-y J� APN9 777 OWNERNAME L^✓/y SI Y0L.,P?0r&R J PVWt*PHONE 3! I� � t��^ EMAIL STREET ADDRESS 7 0 4,! ��,J K`j�„f,J 1001 CITY, STATE,ZIP (GI- `6/1W7 p f Q FAX CONTACT NAME �i'�i/ q/t C/ PHONE 311,1 7j—?r E-M 1II STREET ADDRESS CITY,STATE,ZIP 7FZ( OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC Y COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTIENGINEPR NAME LICENSE NUMBER BUS.LIC Al COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE -9E OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN RucruRE: ❑ Commercial SAN DITERFACE AREA ❑ Yes 11 No FLOOD ZONE 11 Yes C1 NO DESCRIPTION OF WORK IfQ) 5'd) -Tf,/612. '11-M RIEW 1Sn �6� -•�- TOTAL VALUATION: 00ON By my signature below,I certify to each of the following: I am the property owner or authorized agent to act an the property owner's behalf. I have read this application and the information I hav provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating Id g co cn a orize representhtives of Cupertino to enter the ab e-id tiff perry for inspection purposes. < < Signature of ApplicandAgent � h Date: � ' SUPPLE AL INFORMATION REQUIRED � f a &HFMiscApp_2011.doc revised 03/16/11