13070054CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20924 ELENDA DR
CONTRACTOR: PACIFIC NORTHSTAR
PERMIT NO: 13070054
MECHANICAL
OWNER'S NAME: SAMUEL H ICATZ
10381 N PORTAL AVE
DATE ISSUED: 07/09/2013
OWNER'S PHONE: 4087258671
CUPERTINO, CA 95014 PHONE NO: (408) 353-4145
JOB DESCRIPTION: RESIDENTIAL COMMERCIALE]
❑ LICENSED CONTRACTOR'S DECLARATION
r%6 117:9
INSTALL 1" (N) GAS LINE FOR (E) FURNACE, WATER
License Classi} Lic..
BEATER & STOVE (ABANDON PIPE UNDER SLAB).
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Contractor /�a�; (�,C �?�h5iAZ Date . 1
INSTALL
I hereby affirm that I am licensed under the provisions of Chapter 9
(N) GAS STUB FOR FUTURE USE
(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
Valuation: $2500
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
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
APN Number: 32630021.00 Occupancy Type:
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
WITfIIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
180 DAYS + CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of -Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Is ate:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point so ce regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Date l
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑O ER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby at hat I am exempt from the Contractor's License Law for one of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the followi o reasons:
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)
HAZARDOUS MATERIALS DISCLOSURE
I, as owner of the property, am exclusively contracting with licensed contractors to
the (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
construct project
California Health & Safety Code, Sections 25505, 25533, and 25534:.I will
1 hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
a Certificate of Consent to self -insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
I have and will maintain
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
with th Cupertino Municipal Code, Chapter 9.12 and
performance of the work for which this, permit is issued.
will maintain compliance
he eaSafety Code, Sectio s 25 5,25533, and 25534.
Health & Safe
tH
I have and will maintain Worker's Compensation Insurance, as provided for by
n
i
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:/
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
CONST CTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
to the Worker's Compensation provisions of the Labor Code, I must
n lending agency for the performance of
I hereby affirm that there onsted
become subject
forthwith comply with such provisions or this permit be deemed revoked.
t is issued (Sec. 3097, Civ C.)
work's for which this permit (S
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
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
FAX
COACT NAME ' IPHOQE-MAIL
^ s E MA
f; yd !JiL5—
STREET ADDRESS /� CITY, STATE, ZIP FAX
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❑OWNER ❑ QWNER=BUII.DER:: 0 OWNER AGENT g7CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT 11ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME r: C r LICENSE NUMB C2�LICENSE TYPE BUS. LIC #
C ANY AME E-MAIL FAX
; � CY - 3S' —3
STREET ADDRESS CITY, STATE, IP PHONE
i, i} ;) •w�.o r OJC/ '353 -q I off
ARCHITECT/ENG IINEER NAME LICENSE NI ER BUS. LIC #
, i I
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS::!CITY, STATE, ZIP PHONE
USE:OF ❑ SFD 'i DUPLEX MULTI.FAMB.Y PROJECT INWILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN
BUII,.DING•. 11 Cl
. URBAN INTERFACE AREA �, NO FLOOD ZONE .0 --NO EICHLER HOME? No
DESCRIPTION OF WORIi
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dual1�/✓`G! ✓r AAe�CN%Yt 71J1/ �S! 2
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TOTALUAi. i I�,j I �I �,
Bymy signature below; I cert�fy't'o l of the following: I am the property owner or authorized agent to act on the prope owner's behalf. I have read flus
application' and the uiformation 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;to uildin o traction. I authorize representatives of Cupertino to enter the above- den ed property for inspection purposes..
Cirmafirce nfAnnlicant/A¢ent ' !ii" I'� �- Date: 71 /
MEPMiscApp_2011.doc revised 06121111
CITY OF CUPERTINO
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VIOU 1 c'TTM A 9rn72 — 1P.TTT1.1 1T%TV DIVICIC)N
LaADDRESS:
20924 ELENDA DR
QTY/FEE
DATE: 07/09/2013
REVIEWED BY: MELISSA
BP FEES
APN: 326 30 021
BP#:
*VALUATION:
1$2,500
*PERMIT TYPE: Plumbing Permit '
#
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
p
Permit Fee:
PENTAMATION 1 RPGAS
PERMIT TYPE: i
USE:
WORK
INSTALL 1" N GAS LINE FORE
FURNACE WATER HEATER & STOVE ABANDON PIPE
SCOPE I
UNDER SLAB). INSTALL (N) GAS STUB FOR FUTURE USE
APPLIANCE / EQUIP TYPE
FEE ED
QTY/FEE
QTY
UNITS
BP FEES
Piping, Gas <=4 Outlets.
1PGASRES
1
#
$70
Permit Fee:
Supp/. Insp Fee
PME Unit Fee:
$70.00
PME Permit Fee:
$47.00
Construction Tax:
Administrative Fee: IADMIN
$44.00
Work Without Permit? ® Yes (j) No
$0.00
TOTALS:$70
Travel Documentation Fee: ITRAVDOC
00
a "
ON
Mech. Plan Check Plumb. Plan Check 10.0 1 hrs $0.00 Dec. Plan {heck
Tech. Permit Fee:Plumb. Permit Fee: IPPERMIT 1>lec. Permit Fee:
Other ;b9ech. Insp.ED Other Plumb Insp. 0.0 hrs $47.00 Other Eke. Insp.
E3
Allech. Insp. Fee: Plumb. Insp. Fee.: Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other uepartmems (ie. rianning, ruunc rrorns, Parc, aunssuty mac— L ••-1 —1..•.••
L _ _Cnntact the Dent for addn'l Info.
FEE ITEMS (Fee Resolution 11-053 E . 7f /1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check:
$0.00
Permit Fee:
Supp/. Insp Fee
PME Unit Fee:
$70.00
PME Permit Fee:
$47.00
Construction Tax:
Administrative Fee: IADMIN
$44.00
Work Without Permit? ® Yes (j) No
$0.00
Advancer/ Plan.zing Fees,.
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
- ..
$209.50
$0.00 OA7�FLE
5
$209.50
�1 Revised: 07/01/2013