12040054CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10181 FINCH AVE
CONTRACTOR: A & A PLUMBING
PERMIT NO: 12040054
OWNER'S NAME: BETHEL LUTHERAN CHURCH
1030 E EL CAMINO REAL STE 248
DATE ISSUED: 04/10/2012
OWNER'S PuoNE: 4082528500
SUNNYVALE, CA 94087
PHONE NO: (408)738-8878
❑ LICENSED CONTRACTOR'S DECLARATION
r r r
�j"DI d
3 7 V
BUILDING PERMIT INFO: BLDG ELECT PLUNIB
License Class Lic. 9 0 %
r r— r
,/� L(— lG � `L
NIECII RESIDENTIAL CONINIERCLM.
Contractor /� 1 V'.R �C7�c Ualc
I hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REPLACE BROKEN GAS LINK A f REAR 01' COMM BLDG
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
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. FI Floor Area:
Valuation: S4500
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 the work for y�yrs
permit is issued — ----
APN Number: 37503022.00
Occup:mcyTypc:
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 stale 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 DAYrF OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments.
costs, and expenses which may accrue against said City in consequence of the
7
grinning of this permit. Additionally, the applicant understands and will comply
Issued by: a_ Date:
withal non -point s urce regulations per the Cupertino Municipal Code, Section
9.18. /
< �!
F%L ` % /�
RF; ROOFS:
Signature Datc _�
All roofs shal I be inspected prior to any rooting material being installed If a roof is
"
installed without fist obtaining an inspection, I agree to remove all new materials I'or
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicane Date:
1 hereby affirm that 1 um 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
IIA7-ARDOUS NIA1 ERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 695 of the
California Ileallh & Safety Code, Sections 25505, 25533, and 25534. I will
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 Qualiy Monagemenl District
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections -505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date: 7
rennet 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. IC alter making this certificate of exemption, I
CONS'T'RUCTION LENDING 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.)
Lendcr's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and stale 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,
ARCIIITECT'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
9.18.
Signature Date
CITY OF CUPERTINO
Imo` Y//JI FFF FCTIMATOR - BUILDING DIVISIO.
APPLIANCE / EQUIP TYPE
ADDRESS: 10181 finch ave. DATE: 04/10/2012
RE
QTY
APN: I BP#:
V.
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteratio
PRIMARY Commercial Building
#
PE
PE
USE:
/ircc.
Pe/ inil Fee:
WORK
re lace broken gas line at rear of comm. bldg.
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 hrs $0.00
QTY
UNI
Piping, Gas <=4 Outlets
1PGASRES
Orha
1
#
,/loch. I ... p. rls•:
Ph"'A bop. Fro:
/ircc.
Pe/ inil Fee:
Snppl. hn'p Fee
PME Unit Fee:
$65.00
PME Permit Fee:
$44.00
TOTALS:
Consn w -tion Tas:
NOTE: This estimate does not include fees due to olher Departments (i.e. manning, ruotic ;;arra,
District, etc . ,rear ec.. u.c v --- —..nom
FEE ITEMS (Fee Resohuion 11-053 EB: 711111)
.I fcch. Ilan Ch,rk
Plumb. Plan Check 0.0 hrs $0.00
IJU':
,LL•elr. Penuir Fee:
Plumb. Permit Fee: IPPERMIT
Orha
Orhrr Jlech. Insp.
Other Plumb Insp. 0.0 hrs $44.00
,/loch. I ... p. rls•:
Ph"'A bop. Fro:
/ircc.
NOTE: This estimate does not include fees due to olher Departments (i.e. manning, ruotic ;;arra,
District, etc . ,rear ec.. u.c v --- —..nom
FEE ITEMS (Fee Resohuion 11-053 EB: 711111)
_. _..__._
FEE
___ _ _
QTY/FEE
__-
MISC ITEMS
Pl017 ChuCk l' e:
.Supp/. PC Fcv
PME Plan Check:
$0.00
Pe/ inil Fee:
Snppl. hn'p Fee
PME Unit Fee:
$65.00
PME Permit Fee:
$44.00
Consn w -tion Tas:
Administrative Fee: ]ADMIN
$41.00
Work Without Permit? O Yes Q No
$0.00
,I rlrnrtnd 1'lunuing Peas:
i
Travel Documentation Fee: ITRA VDOC
$44.00
Strong Motion Fee: 1aSEISMICO
$0.95
Select an Administrative Item
131dL Slds Commission Fee: IeCRSC
$1.00
- SUBTOTALS:
$195.95
$0.00 TOTAL F
EE:: 1� $195.95
Reviser : 04/01/2012
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 37503022.00
DATE ISSUED.......: 04/10/2012
RECEIPT #......... BS000016501
REFERENCE ID # ...: 12040054
SITE ADDRESS .....: 10181 FINCH AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA ......:
OPERATOR: SylviaM
COPY # : 1
OWNER ............: BETHEL LUTHERAN CHURCH
ADDRESS ..........: 10181 FINCH AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3410
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
195.95
---------------
195.95
VOICE ID DESCRIPTION
-------- ----------------------------
202 UNDERFLOOR PLUMBING
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
REFERENCE NUMBER
--------------------
6394
VOICE ID DESCRIPTION
-------- ----------------------------
301 ROUGH PLUMBING
506 GAS TEST
RECEIVED FROM ....:
A & A PLUMBING -
CONTRACTOR .......:
MIKE FOX LIC
# 25401
COMPANY ..........:
A & A PLUMBING
ADDRESS.,..........:
1030 E EL CAMINO REAL STE 248
CITY/STATE/ZIP ...:
SUNNYVALE, CA
94087
TELEPHONE.........:
(408)738-8878
FEE ID
UNIT QUANTITY
AMOUNT PD
-TO -DT
THIS REC
----------
NEW BAL
----------
----------
1ADMIN
-----------------------
HOURS 1.00
--------------------
41.00
0.00
41.00
0.00
1BCBSC
VALUATION 4,500.00
1.00
0.00
1.00
0.00
1BPGAS
OULETS 1.00
65.00
0.00
65.00
0.00
1BSEISMICO
VALUATION 4,500.00
0.95
0.00
0.95
0.00
1PPERMITFE
FLAT RATE 1.00
44.00
0.00
44.00
0.00
1TRAVDOC
FLAT RATE 1.00
44.00
0.00
44.00
----------
0.00
----------
TOTAL PERMIT
---------- ----------
195.95
0.00
195.95
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
195.95
---------------
195.95
VOICE ID DESCRIPTION
-------- ----------------------------
202 UNDERFLOOR PLUMBING
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
REFERENCE NUMBER
--------------------
6394
VOICE ID DESCRIPTION
-------- ----------------------------
301 ROUGH PLUMBING
506 GAS TEST
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(cl cuoettino.orD
Y r?LUMRlNr, nApCHAMCAL nII- =irm- nR.ncrc,
MEP
c� 6 TSC
FROIECT ADDRESS
i 1 ./nom-
/2 ✓-�C ,`N' I4
�4
1E
��.� %
OWNER NAME 5 L LJ % ! r , ? �QiYPHONB
j'
^.S �6 D I (O
E MAD.
1J
STREET ADDRESS IMT 1I r / K�. C V �. �N J c C'1 � S / L(
FAX
CONTACT NAME COAD l
`�-� �'i
PHONE
E-MAQ.
STREET ADDRM ,''•
CITY, STATE ZW
FAX
❑ OwNER ❑ OWNER-aunDER ❑ OIVNERACENT ❑ CONTRACTOR ❑ CONTNACTORA(]ENT ❑ ARCIDt= ❑ ENGINEER ❑ DEVELOPER ❑ TENANT'
CONTRACTOR NAME �/J
/�' � L
110ENSBNUMBER6,/S
El ' jj'P a G
.S
BUS. LIC0
,I
COMPANY NAME t /I / /
/Jy (� /� T
EMAIL
FAX
CC
STREET ADDRFS4 /630G L I :iC(lN1.L
DP
sv/o 3:-"x-t,cCl 7yo e-)
PHONE
ARCH17SL VFNDBNEER NAME
LICENSE NUAfl3ER.
BUS LIC 0
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑SFO.DUPLEX ❑ MULTbFAMMY
BURDDIO: ODMMERCML
PROJWTINWIDLND❑Y6
URBAN INTERFACEAREA ❑ NO
PROJECT[N ❑YES
FLOOD ZONE ❑ NO
IS THE RL00 AN ❑YES
Elailm Homm ❑ NO
DFSCRIPTION OF WORK
Pe- 12 le,- e 1-02 r /-
�7 `
TOTAL VALUATION: 6 b
REBY:
By my sigoaDae below, I certify to each of the Inllowb .. I am the property owner w authorized ageut to act on the property a ces behalf. I have read tbis
application and the ibbrmation I have provided is C j bave read the Description of Work and verify it is accware. I agree m comply vitt all applicable local
wdiamtces and stare lava rela�g m building Daa I amhoriu represeotatves of CaperDaa to enter the above -identified property Cw iwpecdon poFposa.
Signature ofAppG®dAgene L4-�— Dare: C,
SUPT AL INFORMATION REQUIRED
.
OFFICE USE ONLY
u
E�- Et h ECOUNTER
d
Y
❑ RXPRESS
u
w
u
❑ STANDARD
❑ LARGE
❑ MAJOR
MEPA&cApp_2011.dac revised 0621111