13080164CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23400 VIA VENTURA UNIT 22
CONTRACTOR: BAY AREA FIREPLACE
PERMIT NO: 13080164
CONSTRUCTION &
OWNER'S NAME: HENRY LESSING
679 BOLD DR
DATE ISSUED: 08/22/2013
OWNER'S PHONE: 6509647762
SAN JOSE, CA 95111
PHONE NO: (408) 266-1107
❑
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALE]
LICENSED CONTRACTOR'S DECLARATION
License Class C2_ L�i�c. # 9 I Y 0
INSTALL GAS LINE FROM METER TO FIREPLACE FOR
Alpe., gi_t l �ut
Contractor e.Gt, ate 3
GAS
LOG
I hereby affirm that I am licensed under the 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: $1500
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 which this
APN Number: 34255007.00
Occupancy Type:
permit 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 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 LAST CALLED INSP CTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
:rM
costs, and expenses which may accrue against said City in consequence of the
' f
Date: Z7
granting of this permit. Additionally, the applicant understands and will comply
Issued by:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
ROOFS:
Signature Date
r
All roofs shall be inspected prior to roofing material being installed. If a roof is
any
any
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER 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
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
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. I 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 emif 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 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 25505,25533, and 34.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date: t/
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
4000-11,
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
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.
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
9.18.
Signature Date
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISC
(408) 777-3228• FAX (408) 777-3333 • building6l)cupertino.org \i1,,V
PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS
N* ;:
APN # 3q Z
CC 06-7
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PHONF„ SE
10 726Z
-MAIL J_ V
STREET ADDRE S TN
APi
CITY, STA P
FAX
CONTACT N E
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STREET ADDRESS
CAQ
CITY, STATE, ZIP
FAX
❑ OwNER ❑ OwNER-BUHJ)ER ❑ OWNER AGENT
CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
NTRACTOR NAME
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6;1
LICENSE NUMBER
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LIC SE TYPE
BUS. LIC #
COMPANY NAME
tFAX
E-MAH,,.j/AC
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SID or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WHALAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN
FLOOD ZONE
❑ YES
❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK .
mezC�
4
Com' p
TOTAL VALUATION: + �v
RECEIVED B .
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the o erty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accuraY. I agree to comply with all applicable local
ordinances and state laws relating to building constructi r sentatives of Cupertino to enter the above -identified prope for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLgRNTAL INFORMATION REQUIRED
OFFICE USE ONLY
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❑ OVER-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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❑ LARGE
❑ MAJOR
MEPMiscApp 201 Ldoc revised 06/21/11
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CITY OF CUPERTINO
WN FEE ESTIMATOR — BUILDING DIVISION
lialADDRESS:
23400 via ventura #22 DATE: 08/22/2013
APN: BP#:
REVIEWED BY: Mendez
"VALUATION: 1$1,500
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
USE: SFD or Duplex
PENTAMATION
PERMIT TYPE: 1 RPGA A
WORK
install gas line from meter to fireplace for gas to
SCOPE
Suppl. PC Fee: Reg. OT
Meeh. flan Check Plumb. Plan Check 10.0 1 hrs $0.00 Elec..Plan Check
iLlech. Permit Fee: Plumb. Permit Fee: IPPERMIT Elec. Permit Fee:
Other Merh. Inch. Other Plumb Insp. 0.0 hrs $47.00 Other Dec. Insp.
fltech. Insp. Fee: Plurnb. Msp. Fee., Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Di.ctrirt_ otr_ )_ Thoco foot aro hovod an tho nroliminary infortnadon ovailahle and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 #
$70.00
Plumbing
IPGASRES Piping, Gas <=4 Outlets
Suppl. PC Fee: Reg. OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -0 Reg. ® OT
0,0
hrs
$0.00.
PME Unit Fee:
$0.00
PME Permit Fee:
$47.00
(,onswuction Tax:
Administrative Fee:
IADMIN
$44.00
Work Without Permit? 0 Yes (E) No
$0.00
Advanced Planning; Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
0
i
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion Fee:
IBSEISMICR
$0.50
Select an Administrative Item
Blda Stds Commission Fee: IBCBSC
$1.00
�-
$139.50
$70.00N
$209.50
Revised: 07/01/2013
08115/2013 10:38 6509647762 PAGE 02/04
THTORUM
AT RANO( F�, I ANTONIO
August 13, 2013
Mr. & Mrs. Lessing
23500 Cristo Rey .Drive.V#22
Cupertino, CA 85014
Dear Mr. $ Mrs. Lessing
This is to inform you that Management has reviewed and approved your request for
making the following renovations to your unit #V22 as outlined in your Agreement for Unit
Alteration.
Convert wood -burning fireplace to a gas fireplace.
You have stated licensed contractor Bay Area Enterprise will be doing the construction
work. Please note that proof of general liability insurance, which includes The Forum as
additionally insured, needs to.be submitted to The Forum prior to any work being done.
Please also note that a permit for the gas line installation will need to be obtained before
any work may begin and a copy on file with he Director of Plant Operations -
Please be advised that `in.making the above improvements, you accept responsibility for
the maintenance. repair. damages, and liability as a result of these changes. In addition,
the Board reserves.the,right to remove and/or restore any architectural. changes added
by you or your predecessor in order to maintain the general attractive appearance of The
Forum and to safeguard the integrity of the original design.
Approved by,
Nancy Kao
Executive Director
NK/al
Co.
Richard Mohler, Architectural. Review Committee
Peter Dine, Director of -Plant Operations
Relocation Department
Library
www.experiencetheforum.com I 23500 Cristo Rey Drive, Cupertino, CA 95014 I. 650 944 0100 1
California RC FE# 435200344 I @ Equal Housing Opportunity I GOA# 204 8,
0811512013 10:55AM [Job No. 67921 1210002