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12010044 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21917 ALCAZAR AVE CONTRACTOR:MARTI'S PLUMBING PERMIT NO: 12010044 OWNER'S NAME: PIOTRKOWSKI MICHAEL N AND LAURIE 171 BRANHAM LN STE 10418 DATE ISSUED:01/05/2012 OWNER'S PHONE: 4154202460 SAN JOSE,CA 95136 PHONE NO:(408)375-3190 ❑ LICENSED CONTRACTOR'S DECLARATION r q BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# ['5c� v(3 F MECH RESIDENTIAL COMMERCIAL Contractor��l1fi�'T/ /'�C►�� D e -S Z I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL TANKLESS WATER HEATER (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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2200 t 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 permit is issued. APN Number:35715072.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ]sued by:'/ "°�"�' �' l Date: Z Sign Signature .Date � S� � � RE-ROOFS: ❑ OWNER-BUILDER DECLARATION. All roofs shall be inspected prior to any roofing material beiig installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE. declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 255059 25533,and 25534. 1 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 Owner o or' age Compensation laws of California. If,after making this certificate of exemption,I r._ Date: become subject to the Worker's Compensation provisions of the Labor Code,I must e� forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address 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 granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21917 alcazar I DATE: 01/05/2012 REVIEWED BY: bobs. APN: I BP#: "VALUATION: 1$2,200 1 'PERMIT TYPE: Plumbing Permit I PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION PRWHEATR USE: I PERMIT TYPE: WORK install tankless water heater. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1 PRWHEATR 1 # $26 TOTALS: I I I 1 $26.001 I I Plumb.Plan Check 10.0 I hrs $0.00 I I IPlumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs I $44.00 Ll 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 prelininary information available and are only an estimate. Contact the Dept for addn I info. FEE ITEMS (1•ee Resolution 11-053 Eff. 7"1.%11) FEE QTY/FEE I MISC ITEMS n PME Plan Check: $0.00 n PME Unit Fee: $26.00 PME Permit Fee: $44.00 n Administrative Fee: 1ADMIN $41.00 Work Without Permit? ® Yes Q No $0.00 1 Travel Documentation Fee: ITRAVDOC $44.00 Strona,Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $156.50 $0.00 TOTAL FEE: I $156.50 Revised: 1/01/2012 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RTI N O Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: Z I PERMIT# [ �� OWNER'S NAME: j K�_ - PHONE# - 3 t 7-6 — GENERAL CONTRACTOR: tf%G%Ple mac.r9-2'—',*Ve 2� BUSINESS LICENSE# `/�r'5�& z`' ADDRESS: /t Z G- /Aj I 11-e CITY/ZIPCODE: �/�5//45 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRAC ORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: - 5 Signature Date Please check applicable subcontractors and complete the following information: IV SUBCONTRACTOR BUSINESS NAME I BUSINESS LICENSE # Cabinets & Millwork Cement Finishing I J Electrical - - Excavation Fencing Flooring/ Carpeting ILinoleum /Wood Glass / Glazing Heating Insulation Landscaping iLathing I J Masonry- Painting /Wallpaper Paving Plastering I 1I Plumbing Roofing Il I Septic Tank - Sheet Metal Sheet Rock I Tile Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERT{NO (408)777-3228•FAX(408)777-3333•buildingecupertino.orq misc PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS OWNER NAME J' Iu '� I Cris) - / I EMAII STREET ADDRESS L CITY, STATE,21P 7 C[ I FAX Z `I 1 L c. fi t I ( u re CONTACT NAME 1 .� p 7 -7 P �T) STREET ADDRESS I CITY,STATE, ZIP I FAX wOWNER ❑ OWNER-B=ER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACfORAGENT ❑ ARCHITECT ❑ENGDma ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE ER LICENSE TYPE BUS.LIC# V I c"-7,-t` — p j r�ic%fit I c I LICE 3 /Lt!4 x=f EMAIL (7AI FAX (/v j coMPANY NAME � ' %'C,t�[ft-'t t-3/N'�j j�72d/C it.7�-�^'"/� /��- ��Cit1 ��' fc_,e c�r�l STREET ADDRESS _ CITY,STATE,ZIP r PHONE /L r;l• &cU I t L-f I'�`�'//�G- !`�Z� (e_ u.P6'r-I(- i elf n//'I - ARCHI I ECT/ENGINEER NAME I LICENSE NUMBER -.� ,•' _ 7 r• BUS.Llc# COMPANY NAME' E-MAIL — FAX STREET ADDRESS I CITY,STATE,ZIP I PHONE USE OF MR or DUPLEX ❑ MULTI-FAMILY PROJECT IN W, DLAND ❑ YES I PROJECT IN ❑YES 1 IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO I EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: Z/ Z CC,, I RECEIVED BY: 4 /1 Y By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pro�erty owner's behalf. I have read this application and the information 5��is correct. ave read th Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatnstrt I autho ' representatives of Cupertino to enter the above-identified property for inspection pu(poses. Signature of Applicant(Agent: / , Date: d 5-_ / Z I SUPPLEME NTAL INFORMATION REQUIRED ,� OFFICE USE ONLY 1�'OVER-THE-COUNTER G ❑ EXPRESS Y U W ❑ STANDARD T V ❑ LARGE ❑ MAJOR MEPMIscApp_201 Ldoc revised 06121111