12060088 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10325 PINCH AVE CONTRACTOR PERMIT NO: 12060088
OWNER'S NAME: SPENCER HILARY H AND A T � wy-SCG- I DATE. ISSUED:06/142012
OWNER'S PHONE: 4157331560 PDONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f ELECT F PLUMB r
License Classs� 1C_5n - I_,Lic.N 6 lOs 'J r- r
Contractor
1"��V' ) I�tf(.Y'kN1C Date /- MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL NEW WATER I(EATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in run 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
perlimrmnce of the work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as provided for by Sq.FI Fluor Area: Valuation:$1450
Section 3700 of the Labor Code,for[lie performance of the work for which(his
permit is issued
APN Number:37543008.00 Occupancy Type:
APPLICANT CF-RTI FICATION
I certify(hal I have mad this application and state that the above information is
correcl. I agree to comply with all cityand county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accme against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting ol'fhis permit. Add ilionally.(he applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section /
9.18. ///1 Issued by: Date:
Signature l/" Date
❑ OWNER-RUILDER DECLARATION RF.-ROOFS:
All roofs shall be inspected prior to any roof ng material being installed.If a roof is
hereby affirm that I um exempt from the Contractor's License Law for one of installed without first obtaining ah inspection,1 agree to remove all new materials for
the following two reasons: inspection.
1,as owner of the property,or my croplo)'ees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant Date:
Business& Professions Code)
I,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 penaly 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 I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided fur by Section 3700 of the Labor Code,for the California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
performance of the work for Which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safely 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 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Qualiy Management District 1 will
maintain compliance%illi the Cupertino Municipal Cade.Chapter 9.12 and the
I certify(hat in the performance of die work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ'any person in any manner 50 as to become subject to the Worker's
Compensation laws of California- If,after making this certificate of exemption,1 Owne or auth ��eg q
become subject to the Worker's Compensation provisions of the labor Code,I must J- vat'✓'-ri'�-+ Dale:
Imthw'i(h comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING.AGE:NCI'
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify'(hat I have read this application and state that the above information is for which this permit is Issued(SCC.3097,CIV C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnifi'and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may,accrue against said City in consequence of the
granting of(his permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section 1 understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: - Sub: Blk: Lot:
APN . . . . . . . . : 37543008 .00
DATE ISSUED. . . . . . . : 06/14/2012
RECEIPT #. . . . . . . . . : BS000017077
REFERENCE ID # . . . : 12060088
SITE ADDRESS . . . . . : 10325 FINCH AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SPENCER HILARY H AND A T
ADDRESS . . . . . . . . . . : 10325 FINCH AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : GARY MILLS
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . .
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
FEE ID UNIT - QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---
-ADMIN HOURS 1 .00 41 . 00 0. 00 41 .00 0. 00
1BCBSC VALUATION 1,450.00 1 . 00 0. 00 1 .00 0. 00
1BSEISMICR VALUATION 1,450. 00 0. 50 0. 00 0 .50 0 .00
1BUSLIC FLAT' RATE 1.00 119. 00 0.00 119 .00 0.00
1PPERMITFE FLAT. RATE 1.00 44 .00 0.00 44 .00 0.00
1PRWHEATR UNITS 1.00 26. 00 0 .00 26 . 00 0 .00
1TRAVDOC FLAT RATE 1 .00 44 .00 0 .00 44 . 00. 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 275 .50 0 .00 275.50 0.00
METHOD OF PAYMENT .' AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 275. 50 AMEX
---------------
TOTAL RECEIPT 275. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER. HEATER
Community Development
4 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CRY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
03 Rud
OWNER'S NAME:TY.o�� ` Cc PHONE #
GENERAL CONTRACTOR Nle �S lC' FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork -
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10325 finch ave. DATE: 06/14/2012 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: $1,450
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK install new water heater.
SCOPE
APPLIANCE/EQUIP TYPE r ' , FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $26
TOTALS: $26.00
,blrch. /'Ian Cheek Plumb.Plan Check 0.0 hrs $0.00 /ileo. Plan Check
me,;h. Perwh Fee: Plumb. Permit Fee: IPPERM1T Ver. Pennh Fre:
(Aho d c,h. Imp. Other Plumb Insp. 0.0 hrs $44.00 U+her Elce.Insp. Lj
Meech. hnp. Fee: Numb. Insp. ret: lilee. Insp. Fee:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prelindna information available and are only an estimate Contact the De t or addn7 info.
FEE ITEMS(Fee Resohnion 11-053 Eff'' 7/1/11) FEE QTY/FEE MISC ITEMS
Plan C/rock Fee:
.Supp/. PC Fee
PME Plan Check: $0.00
Permit Fee:
S'uppl. Ihsp Fee
PME Unit Fee: $26.00
PME Permit Fee: $44.00
Consn•uction Tai.
Administrative Fee: IADMIN $41.00
Work Without Permit? O'Yes 0 No $0.00
Advanced Plunaigc4 Fees:
Travel Documentation Fee: ITRA VDOC $44.00
Suone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
131de Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $156.50 $0.001 TOTAL FEE: $156.50
Revised: 06/05/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O I
sc
CUPERTINO (408)7T7-32288 -FAX(408)777-3333•buildinaQcuoerdno.orD L19O
PLUMBING
ErMEFA�CHAMCALELECTRICAL MfISC17.IA1VE0Us
PRO=ADDRESS 0�52'5— �A-Y1G APNd
owN O '56er\uj-- E-MAIL
STREET ADDRESS CT',STATE ZIP FAX
CONTACT NAME�1°�-� /Jp P(1106 _ to—;85 E MAfL
STREETADDRESS I�^ 1. (t/]�-� STATE 78 n •.J
❑OWNER ❑ OWNER-BUDDER ❑ OWNER AGENT fI(c,,CONIRA, CTOR ❑CONTRACTOR A= ❑ AR=c-r ❑wGD+Et ❑ DEVELOPER ❑ TENANT
CO OR NAME u TYPE BUS.LIC a
0.f till
COMEANYN \ eCM`0.11(
STREET ADDRESS 31 o JV CITY. yzE ..
- / lel PBD IDs(o l92
ARCHr=1ENGINEER NAME LICEN ER BUS.IJC4
COMPANY NAME' 'E- FAX
STREET ADDRESS CITY,STATE PHONE
USE OF ErsFD m OUI,LE E ❑ muu. FAmmy PROJECTMWILDLAND ❑ YES PROJECTuN ❑YES I5THE3113GAH ❑ YES
BUILDING: ❑CONOAERCLV. URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME ❑ NO
DESCAIFRON OF WORK
e.e_ e cJe-r kecACr cRD S zc
TOTAL VALUATION: Q RECEIVED BY:
By my signature below,I certify m each of the following: I am the property owDer or aurhorimd agent to act on the property owner's behalf. I have read this
application and the information I have vided is conecL 1 have read the Desaiption of Work and verify it is accurate. I agree m comply With all applicable local
ordinances and state laws relating m —d ng`con`structiim I m representatives of Cupertino to enter the above-i tified pe—�I ins/plec/tion/pu�i$ases.
Signature of Applicant/Agent: / //Gr� Dam: (S/ /y` —o
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
N OVER-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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MEPMucApp_2011.doc revised 06121111