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13110154 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20805 GREENLEAF DR CONTRACTOR:GREAT AMERICAN PERMIT NO:13110154 PLUMBING CO INC OWNER'S NAME: LEON HAYES P O BOX 26942 DATE ISSUED: 11/22/2013 OWNER'S PHONE: 4082523573 SAN JOSE,CA 95159 PHONE NO:(408)279-1515 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL11 License Class CA Lic.# 5 , INSTALL GAS LINE UNDERGROUND 120 SQ FT Contractor i- Date a �3 I hereby a %al1 & tcetfstd 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4400 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:32609004.00 Occupancy Type: permit is issued. Y) 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 PO 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 D=M 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 Issued b Date: granting of this permit. Additionally,the applicant.understands and will comply Y' with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. �/ RE-ROOFS: Signature 7y l . Date o�o�A_� 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. ❑ 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 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 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 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 25505,25 ,a dd�255534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agentir '%�y Date: 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 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 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 MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 1-� V 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 X00 CUpERTtNO (408)777-3228•FAX(408)777-3333•building Cc�cupertino.org `n MISC PLUMBING [:]MECHANICAL ❑ELECTRICAL ❑✓MISCELLANEOUS PROJECT ADDRESS OQ /y� �, , e� APN# OWNER NAME Q `/ ��•sss111 PHONE �5 5 E-MAIL 0� STREET ADDRESS C STATE,ZIP CA F CONTACT NAME o` PHONE E-MAIL W STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER -❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS TATE,Z PHONE�y �-7� (� S ARCIRTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX MULTI-FAMILY PROTECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO - DESCRIPTION OF WORK .`*r,'. ..'-2-S., 9 TOTAL VALUATION: L� RECsr By my signature below,I cer4ify to each of the following: I am the property owner or authorized agent to act or(tholoperty 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 acc,gryte. I agree to comply with all applicable local ordinances and state laws relati to uilding construction I a thorize representatives of Cupertino to enter the e-id tified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED oEFicEu� of r a %'' OYER HE-GOiJ1YTER�IE� --ma , � � a STANDAltD, *„ MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20805 greenleaf dr DATE: 11/21/2013 REVIEWED BY: MENDEZ APN: BP#: *VALUATION: 1$4,400 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY PENTAMATION 1 RPDP USE: SFD or Duplex' PERMIT TYPE: i WORK install as line under round 120 sq ft SCOPE WN Xlech. Tian Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check iVlech.Perrnit Fee: Plumb.Permit Fee: 1PPER1l1IT F.Ic<c. Permit Pee: Other.Itch.Insp. Other Plumb Insp. 0.0 hrs $47.00 Other Eke,Insp. ,Zech.Insp.Fec: Plyn7b.Insp. Fee: Elec.Insp,Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District eta). These ees are.based on the. relimina information available and are only an estimate Contact the Dept for addn'l info, FEE ITEMS(Fee Resolution 11-053 E . 7f 11113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # Plumbing Supp/:PC Fee: Q Reg. OOT : .0:0 hrs $0.00 $47.00 1PREPPIPE Piping,Floor PME Plan Check: $0.00 Permit Fee: $0.00 Suppl.Insp.Feer Reg. OOT : o. hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee:. $47.00 Cons wuction :Tax Administrative Fee: IADMIIV $44.00 O Work Without Permit? O Yes Q No $0.00 O Advanced Planning Fee:. $0.00 Select a Non-Residential Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure ®A Strong_Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $139.50 $47.00 F- � E $186.50 s ` n Revised: 10/01/2013