13090163 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10181 FINCH AVE CONTRACTOR:BENJAMIN FRANKLIN PERMIT NO: 13090163
PLUMBING
OWNER'S NAME: BETHEL LUTHERAN CHURCH 22 DIGITAL DR DATE ISSUED:09/23/2013
OWNER'S PHONE: 6502249018 NOVATO,CA 94949 PHONE NO:(415)506-0400
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL 11
License Class Lie.# 5 5 7 t S 7 REPLACE(E)GAS LINE FROM METER TO FOUNDATION
Z ' CONNECTION
Contractor ate
I here rm:tht
alamOisi,
se oder the provisions of Chapter 9
(commencing wS o )of Division 3 of the Business&Professions
Code and that r e 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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2500
I have and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:37503022.00 Occupancy Type:
ermit 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 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 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 Z71
granting of this permit. Additionally,the applicant understands and will co Issued by:
with all non-point source regulations per the Cupertino Municip ode,Section
9.18.
RE-ROOFS:
Signature Date 3 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNE IL DECLARATION
Signature of Applicant: Date:
I hereby affirm that 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)
1,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. 1 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 emit 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 25534.
Section 3700 of the Labor Code,for the performance of the work for which thisr
permit is issued. Owner or authorized agent: Date:
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 of exemption,I CONSTRUCTI G 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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 bMEP
is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION - 1 D
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 � MISC
CUPEFtTINC (408)777-3228•FAX(408)777-3333•build ingsacugertino.orp
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROTECT ADDRESS V 9 ' iAPN# J
OZ_
7
, t,jci4 �,r
0 ER NAME E-MAIL
? A(_ I-J7 Pga
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STREET ADDESS CITY, STATE,ZIP FAX
O i (G1 C( GcJPt_114 7 o1 f A . 9 O/
CONTACT NAME KIM AT BEMJAMIN FRANKLIN PHONE 415-459-3266 E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
22 DIGITAL DR. STE ONE NOVATO, CA 94949 415-506-0410
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ® CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
857357 C36
COMPANY NAME E-MAIL FAX 415-506-0410
BENJAMIN FRANKLIN PLUMBING
STREET ADDRESS CITY,STATE,ZIP PHONE 415-459-3266
22 DIGITAL DR. STE ONE NOVATO, CA 94949
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ; Commercial C rf L)acH URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No
DESCRIPTION OF WORK 'A L
TOTAL VALUATION: S Ob RECEIVED BY
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property 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 accurate. I agree to comply with all applicable local
ordinances and state laws relating to building constructio ze r sentatives of Cupertino to enter the above
p-identified property for inspection purposes.
Signature of Applicant/Agent: Date: /
-SCPPLEMENTAL INF TION REQUIRED C1ff CE USE ONLY
SER=T,HE-COUNTER
H ❑ EXPRESS
34
❑ STANDARD
❑ LARGE
0.
❑ MAJOR
MEPMiscApp_2011.doc revised 03116/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10181 FINCH AVE DATE: 09/23/2013 REVIEWED BY: MELISSA
APN: 375 03 022 BP#: *VALUATION: 1$2,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1 CPGA
WORK REPLACE E GAS LINE FROM METER TO FOUNDATION CONNECTION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1PGASRES 1 # $70
gj
TOTALS: � $70.00
,Llech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
rLtech.Permit Fee: Plumb.Permit Fee: 1PPERMIT Eilec. Permit fee:
Other.-Wech.Insp. Other Plumb Insp. 0.0 has $47.00 Other Elec.Insp. Lj
Ifeck In.sp.fel- Plumb. Insp.fee: Elee.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(r.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on therelimina information available and are on an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Stipp 1.
PME Plan Check: $0.00
Permit Fee:
Supp/, Ins)Fee
PME Unit Fee: $70.00
PME Permit Fee: $47.00
t'onsiruction Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $47.00
Strong Motion Fee: IBSEISMICO $0.53 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$209.531 $0.00W.
INN
ki $209.53
Revised: 08/01/2013
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COMMUNITY DEVELOPMENT DEPAR--MENT
cls: rt`\-XD BUILDING DIVISION-CUPERTIN
APPROVE®
This set of plans and specifications MUST a kept at the
job site during construction. It is unlawful to make any
changes or alterations on same,or to deviate
therefrom,without approval from the Buili ling Official.
M WcGtThe stamping of this plan and specification SHALL NOT
beak 1,"0 permit or to be an approval oft ie violation
ance ot State Law.
DAT t.,
Fri � PERMIT No. 130
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