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15040193CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18000 CHELMSFORD DR CONTRACTOR: CUPERTINO PLUMBING PERMIT NO: 15040193 OWNER'S NAME: RANCHO RINCANADA PARK DISTRICT 2784 S BASCOM AVE DATE ISSUED: 04/27/2015 WN R'S PHONE: 4082528429 CAMPBELL, CA 95124 PHONE NO: (408)253-0618 r ^1 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL � r� Lic Class a�� Lia RANCHO RINCONADA CLUBHOUSE - REPLACE EXISTING WATER HEATER, SAME LOCATION GALLONS) nse b - 4i'/� , Contractor. ' ,� Date 2 j (If (100 I hereby affirm that I am li ensed unde a 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 Sq. Ft Floor Area: Valuation: $5500 performance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by tion 3700 of the Labor Code, for the performance of the work for which this APN Number: 37522104 00 Occupancy Type: p it 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 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 ftYS FROM LAST CALLED INSP CTI N. indemnify and keep harmless the City of Cupertino against liabilities, judgments, / costs, and expenses which may accrue against said City in consequence of theJ060 Ar granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: l with all non -point sou ce regulations er the Cupertino Municipal Code, Section 9 18. `-� RE -ROOFS: Signature11olma Date -' All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ O R -B L ER 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, 25533, and 25534. 1 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 t Cuper o Municipal Code, Chapter :12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health &Safety Code, Seen 25507,12553,31, d 25534. 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 Compensation laws of California. If, after making this certificate of exemption, I CONSTRUC ON LE G AGENCY 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 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 918. Signature Date 2 CUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION \k 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(b)cupertino.orc7 MISC ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS PLUMBING PROJECT ADDRESS APN # �) ,/ L/ / ZZ I / c.. OWNERNAMER,,A,,ClJ //� e � PHONE b2 . 2 E-MAIL STREET ADDRESS ( CITY, STATE, ZIP FAX l N PHONE E-MAILCONTACT � � v (� STREET ADDRESS r CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER 1:1 DEVELOPER ❑ TENANT CONTRACTOR NAME &,,AjV �tt*t;k j NUMBER ICENSE j f 1 LICr— Fly (� BUS. LICCOMPANY NAME L �v E-MAIL FAX STREET ADDRESS S & L(/,1j7 / / 7 CITY, STATE, ZIP /! / P O E -253-0&/f 53 0 ` `f ARCHITECT/ENGINEERNAME /J/I//J v < LICENSENUMBER BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES COMMERC. BUILDING: Ig W URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO r DESCRIPTION OF WORK / off« lUb � TOTAL VALUATION: By my signature below, I certify to each of the follow I am the property owner or auth nt to act on the pro a alf. ver this application and the information I have provi d is co ct. I have rea -the Description ofWork and verify it is acoura . agree to com It applicable local ordinances and state laws relating to buildi onst I aut Ize representatives of Cupertino to enter the above -identified e r inspection purposes. Signature of Applicant/Agent: Date: STJPPLEI\ N ORMATIUN REQUIREDr ` , i ,` roFrzcEusEoiviY, k `' "' r OVER THE�COUNTER - Wp -� ;. H x ❑r " �` � � EXPRESS " ur r'� ?n � � � r rSTAIQDARD L f ` a` Us � y I � a � ,„,❑" )TARGE mom-. y -�r � '� �' ' w MEPMiscApp_201 ].doe revised 06/21/11 CITY OF CUPERTINO r, r, r r Omrnii A r1rn1? — RT TTT .T1TNl-' ilIVI4ION APPLIANCE / EQUIP TYPE 1'Li yvi QTY/FEE QTY UNITS ADDRESS: 18000 CHELMSFORD DR DATE: 04/27/2015 REVIEWED BY: PAUL Ila APN: 375 22 104 BP#: "VALUATION: J$5,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair Commercial Building -------j-PRIMARY PENMIT TY ON PCWHEATR PERMIT TYPE: i USE: WORK RANCHO RINCONADA CLUBHOUSE - REPLACE EXISTING WATER HEATER SAME LOCATION SCOPE (100 GALLONS) APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Water Heater 1PCWHEATR 1 # $29 Pei'miI'e(e: suppl. InSIP Fee PNM Unit Fee: $29.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC $29.00 Strong Motion Fee: IBSEISMICO ;llech. flan Check Plumb. Plan Check 0.0 hrs $0.00 lsr'ec. Plan (..heck 1'ec,'h. permit Fee: Plumb. Permit Fee: IPPERMIT Elea Perniir Fee: O faer Hech. Insp?. Other Plumb Insp. 0.0 �rs$48.00 Other 1',lec: Insp. 1:1ecfi. Insp, 1'ee: Ilhinib. Insp. T'ee: Elec. Insp. Fee: NOTE: This estimate does not inctuae fees aue to Omer vepartrnrni3 �..r.....�....•s, _ ����� _ _. _, __.______, _ _.. ndds°I ;"fn_ District, etc). Iltese fees are nasea on me retirntnur FEEITEMS (Fee Resolution 11-053 Ef . 7/1/131 I.— .—FEE FEE QTY/FEE MISC ITEMS Plan Check Fee: supl�l..I'C:11 ",e PME Plan Check: $0.00 Pei'miI'e(e: suppl. InSIP Fee PNM Unit Fee: $29.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning trees: Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICO $1.54 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 u SUBTOTALS: $172.54 $0.00 TOTAL FEE: �. $172.54 r�cviac. CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18000 CHELMSFORD DR CONTRACTOR: CUPERTINO PLUMBING PERMIT NO: 15040193 OWNER'S NAME: RANCHO RINCANADA PARK DISTRICT 2784 S BASCOM AVE DATE ISSUED: 04/27/2015 WN R'S PHONE: 4082528429 CAMPBELL, CA 95124 PHONE NO: (408)253-0618 r ^1 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL � r� Lic Class a�� Lia RANCHO RINCONADA CLUBHOUSE - REPLACE EXISTING WATER HEATER, SAME LOCATION GALLONS) nse b - 4i'/� , Contractor. ' ,� Date 2 j (If (100 I hereby affirm that I am li ensed unde a 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 Sq. Ft Floor Area: Valuation: $5500 performance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by tion 3700 of the Labor Code, for the performance of the work for which this APN Number: 37522104 00 Occupancy Type: p it 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 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 ftYS FROM LAST CALLED INSP CTI N. indemnify and keep harmless the City of Cupertino against liabilities, judgments, / costs, and expenses which may accrue against said City in consequence of theJ060 Ar granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: l with all non -point sou ce regulations er the Cupertino Municipal Code, Section 9 18. `-� RE -ROOFS: Signature11olma Date -' All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ O R -B L ER 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, 25533, and 25534. 1 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 t Cuper o Municipal Code, Chapter :12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health &Safety Code, Seen 25507,12553,31, d 25534. 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 Compensation laws of California. If, after making this certificate of exemption, I CONSTRUC ON LE G AGENCY 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 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 918. Signature Date 2 CUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION \k 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(b)cupertino.orc7 MISC ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS PLUMBING PROJECT ADDRESS APN # �) ,/ L/ / ZZ I / c.. OWNERNAMER,,A,,ClJ //� e � PHONE b2 . 2 E-MAIL STREET ADDRESS ( CITY, STATE, ZIP FAX l N PHONE E-MAILCONTACT � � v (� STREET ADDRESS r CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER 1:1 DEVELOPER ❑ TENANT CONTRACTOR NAME &,,AjV �tt*t;k j NUMBER ICENSE j f 1 LICr— Fly (� BUS. LICCOMPANY NAME L �v E-MAIL FAX STREET ADDRESS S & L(/,1j7 / / 7 CITY, STATE, ZIP /! / P O E -253-0&/f 53 0 ` `f ARCHITECT/ENGINEERNAME /J/I//J v < LICENSENUMBER BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES COMMERC. BUILDING: Ig W URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO r DESCRIPTION OF WORK / off« lUb � TOTAL VALUATION: By my signature below, I certify to each of the follow I am the property owner or auth nt to act on the pro a alf. ver this application and the information I have provi d is co ct. I have rea -the Description ofWork and verify it is acoura . agree to com It applicable local ordinances and state laws relating to buildi onst I aut Ize representatives of Cupertino to enter the above -identified e r inspection purposes. Signature of Applicant/Agent: Date: STJPPLEI\ N ORMATIUN REQUIREDr ` , i ,` roFrzcEusEoiviY, k `' "' r OVER THE�COUNTER - Wp -� ;. H x ❑r " �` � � EXPRESS " ur r'� ?n � � � r rSTAIQDARD L f ` a` Us � y I � a � ,„,❑" )TARGE mom-. y -�r � '� �' ' w MEPMiscApp_201 ].doe revised 06/21/11 CITY OF CUPERTINO r, r, r r Omrnii A r1rn1? — RT TTT .T1TNl-' ilIVI4ION APPLIANCE / EQUIP TYPE 1'Li yvi QTY/FEE QTY UNITS ADDRESS: 18000 CHELMSFORD DR DATE: 04/27/2015 REVIEWED BY: PAUL Ila APN: 375 22 104 BP#: "VALUATION: J$5,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair Commercial Building -------j-PRIMARY PENMIT TY ON PCWHEATR PERMIT TYPE: i USE: WORK RANCHO RINCONADA CLUBHOUSE - REPLACE EXISTING WATER HEATER SAME LOCATION SCOPE (100 GALLONS) APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Water Heater 1PCWHEATR 1 # $29 Pei'miI'e(e: suppl. InSIP Fee PNM Unit Fee: $29.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC $29.00 Strong Motion Fee: IBSEISMICO ;llech. flan Check Plumb. Plan Check 0.0 hrs $0.00 lsr'ec. Plan (..heck 1'ec,'h. permit Fee: Plumb. Permit Fee: IPPERMIT Elea Perniir Fee: O faer Hech. Insp?. Other Plumb Insp. 0.0 �rs$48.00 Other 1',lec: Insp. 1:1ecfi. Insp, 1'ee: Ilhinib. Insp. T'ee: Elec. Insp. Fee: NOTE: This estimate does not inctuae fees aue to Omer vepartrnrni3 �..r.....�....•s, _ ����� _ _. _, __.______, _ _.. ndds°I ;"fn_ District, etc). Iltese fees are nasea on me retirntnur FEEITEMS (Fee Resolution 11-053 Ef . 7/1/131 I.— .—FEE FEE QTY/FEE MISC ITEMS Plan Check Fee: supl�l..I'C:11 ",e PME Plan Check: $0.00 Pei'miI'e(e: suppl. InSIP Fee PNM Unit Fee: $29.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning trees: Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICO $1.54 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 u SUBTOTALS: $172.54 $0.00 TOTAL FEE: �. $172.54 r�cviac.