12100121 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10699 HALE PL CONI'RACI'OR:KMF PLUMBING PERMIT N0: 12100121
OWNERS NAMF-: LEE KANN 4165 CHEENY ST DA'Z'E ISSUED: 10/16/2012
1OWNER'S PBONF-: 4083943331 SANTA CLARA,CA 95054 PHONE NO:(408)727-1965
'!s7^
LICENSED CONTRACFOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑
COMMERCIAL
License Clan _ J l Lic.4 a /0
,- J� INSTALL MAIN WATER PIPE FROM METER TO HOUSE
Contractor ! Date/ r l /
hereby affirm that I am licensed under the provisions of Chapter 9 A�
(commencing with Section 7000)of Divisinn 3 of the Business&Professions
Code and that my license is in full force and effect.
hereby atliFm under penalt 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:$2800
1 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 ALN Number:32640008.10699 Occupancy Type:
permit is issued
APPLICANTCERTIFICATION
1 certify that I have read this application and slate 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 DA S 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: /v
with all non-point source r ulation r t C penino Municipal Code,Section
9.18. ^
I `n■ IP'1 RF:ROOFS:
Signature Datd D '1 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that 1 an,exempt from the Contractor's License Lase for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BF CLASS"A"OR BETTER
1,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 IIAZARDOUS 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
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: Health&Safety Code,Section 25532(x)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 cmuo m ina tits as defined by the Bay Area Air Qua1i )'Management District 1
performance of the work for which this permit is issued, will maintain compliance with the Cupertino pinnici 1 ode.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sec n .5 5.25 a 534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or outhorizeJ agent: Date!V��/1n k
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 ofexemption,I CONSTRUCTION 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. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANTCERTIFICATION Lender's Address
1 certify that 1 have read(his application and state that the above information is
correct. 1 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 hamdess the City of Cupertino against Iiabilities,judgments, ARCII ITF.CF'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
GENERAL PERMIT APPLICATION 0\ 0 M E r
C COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION r,
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 \� w A I S1v\ C
\
CUPERTINO (408)777-3228• FAX(408)777-3333•buildinaOcuoertino.ora ` �/ '\a/'
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MIISCELLADIEOUS
PROIECTADDRESS O . yj PIC 42 'C'eAPN9 Zco ' O . OO
OWNER NAMETU1 I ✓ n o 3�'y -3331 E-MAIL
STREET ADDRESS,Jr I PAT CITY, SLATE, �^ G I FAX .
�i t
CONTACT NAME PHONE I E-MAIL
STREETADDRESS CRY.STATE, ZIP FAX
❑ OwNER ❑ Ow -BUTIDER ❑ OMNERAG_NT ❑ CONTa/.CIDR El CON CIOR AGc T ARCNTTECr ENGINEER ❑ D"cV Pa ❑ , IANT
CONTRACTOR NAME
/ !� LICENSE NUMBER C6GSdoo LICENSE TYP / I BUS.LICK
COMPANY NAME AA {i I� E-MAIL o v� (� I FAX `'y
STRER ADDRESS LI� `J ll LI I =.STATE �5c>'5 Gr/I Y(n PQ l�� I
ARC'HITECr/FNGA'EER NAME I LICENSE NUMBER BUS.LIC 0
COMPANYNAME' E-MAB. FAX
STREET ADDRESS I CITY,STATE,ZIP PHONE
USE OF ❑SM m DUPLEX ❑ MULTI-FAMILY PROTECT N WG.DLANrD ❑ YS I PROTECT N ❑YES I IS THE BLDG AN ❑ YE
RUILDA'G: ElCOMMERCLAL URBAN INTERFACE AREA NO FLOOD ZONE [I No EICH. HOMc'/ EI No
DESCRIPTION OF WORK 1
GInq GI ) ✓ `i0' ✓ V7�C..)
TOTAL VALUATION: �Oo.w� RECEIVED BY:
By my signanne below,I cerdfy.to each of the following: I am:ne property owner or authorized agent w act on th p--P;6-71 owner's behalf. I have clad this
application and the in`om:ation I have provided is correct. 1 have;cad the 'prion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating towi cons cion. I aur 'u .tatives of Cupertino to enter the above-identi5fi gropc-, y fin[inspection puiposes.
Sign==o;Applicant/Agcnn Dare: 10 �/ (Ci
SUPPLEMENTAL.INFORMATION REQUIRED OFFICE USE ONLY
m ❑ OVER-THE-COUNTER
F ❑ EXPRESS
v
m ❑ STANDARD
V
❑ LARGE
❑ MAJOR
M£PMucApp}Ol l.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
-2-114 ADDRESS: 10699 HALE PL DATE: 10/16/2012 RF1'II's11'ED BY: MENDEZ
APN: 13114: 'VALUATION: IS2,800
*PERMIT"1'YI'F: Plumbing Permit PLAN CHECK•I'1'1'E: Alteration / Addition / Repair
PRIMARYPENTAMATION
USE: SFD or Duplex PGRN71'1' r1 PE: 1RPW A
1vORK INSTALL WATER MAIN FROM METER TO HOUSE
SCOPE
APPLIANCE/ rsQUIP Tl'I'E FEE 11) Q'I'1' UNITS 131' FEES
Water Service 1ePWSVCS 1 # S23
Re-Pipe Interior 1PRREPIPE 1 # $13
I'OT'A LS: $36.00
14u h Phan Checl, Plumb. Plan Check 0.0 hrs $0.00 Pb c Phra c h.,h
61eeb Perunt Pc, Plumb. Permit Fee: /PPERMIT Eiev.Pr,wal F"
Orher,l•*vh, Imp. Other Plumb Insp. 0.0 hrs
sfech. htsp. rx. Month I,t,p Ii,
NOTE: This estimate doer not include fees due to other Departments(i.e. /Tannin„ Public Works. Fire,Sanitary Server District,School
District,etc.). Thesefees tore based on the prefindnan,infornmtion availahle aad are only an estintate. Contact the Det for addn•I info.
FEE ITENIS (Fee Resohtion I1-053 L . 711111) FEE QT'1'/1EE N11SC IT EINIS
Ivan Check Fee:
Sappl. PC ree
PML' flan Check: $0.00
I'vouh lecc"
Snppl lrtslt Fee
PME Unit Fee: $36.00
PME Permit Fee: $45.00
Construction To.s:
Administrative Fee: ]ADMIN $42.00
Work Without Permit? O Yes (D No $0.00
•ltAwnred Plaiting Fees:
Travel Documentation Fee: ITRA VDOC $45.00
Strove Motion Fee: IQSEISA11CR $0.50 Select an Administrative Item
Blde Sids Commission Fee: IRCRSC $1.00
SUBTOTALS: 1 $169.501 $0.001 TOTAL FEF: $169.50
Revised: 10/01/2012