15120181r
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10715 S BLANEY AVE
CONTRACTOR: BLUE HAVEN BUILDERS PERMIT NO: 15120181
OWNER'S NAME: UNDERWOOD JOAN TRUSTEE
1241 ARROYO SECO DR DATE ISSUED: 12/21/2015
OWNER'S PHONE: 4082574185
CAMPBELL, CA 95008 PHONE NO: (408) 205-5806
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL F] COMMERCIAL
REMOVE AND REPLACE WATER HEATER, SAME
License Class Lie. # 9' 3 D 6
LOCATION
Contractor/ y Af /J Ale u S Date
I hereby affirm t�icensed under the provisions of C apter 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: $1000
pformance of the work for which this permit is issued.
O'Ieave 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
is issued. lVo e "lla S — f
APN Number: 36934045.00
Occupancy Type:
permit ye'
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 DAYS FROM LAST CALLED INSPE TI
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the��
T�
granting of this permit. Ad 'tionally, the ap licant understands and will comply
Issued by: Date:
with all non -point sourc a lations p r t Cupertino Municipal Code, Section
RE -ROOFS:
9.18.
Signatur_ Date / /5-
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 (See.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 M icipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Chi'",ns "05, 2 53 , and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Owner or authorized agent Date: a a
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 PERI`[ t APPLICATION! 15/1®1.6l
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 9501'-3255
(408) 777-3228 - FAX (4,08) 777-3333 • buildinalG CUDer<ino.org
PLU],r3L C, ❑bECKA ICAL ❑ELECTIUC?L ❑1,fnSCELLA��OUS
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By my signature below, I certify to each of the following:
I am the pro erty owner or authorized agent to act on the pr pe.- ty owner's behalf. I have read this
application and `ue L-afor^:nation I have provided ' .ect.
I have Yea ' e Description of Work and verify it is accurate. I agree to comply with all applicable local
ordL-.2ances and state laws relit ng to building ..ons .'ction.
property for inspection purposes.
I zu' representatives of Cupertino to enter he above-ident;�15_
Signature of Applicant/Aeent:
Date: % 7 /
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MEP ,'iscApp_?011.doc remised 0 612 1/11
CITY OF CUPERTINO 151a0161
FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 10715 S Blaney Ave
QTY/FEE
DATE: 12121/2015
REVIEWED BY: PAUL
BP FEES
APN: 369 34 045
I BP#:
1PRWHEATR
"VALUATION: j$1,000
*PERMIT TYPE: Plumbing Permit
#
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
J. sr
F-1 I
PENTAMATION PRWHEATR
USE:
L1 I
: 6<;:2..rr1.SZi.: c'e.:
PERMIT TYPE:
WORK
Remove and Replace Water Heater,
Same Location
F
SCOPE
Administrative Fee: IADAIIIN
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Plumb. Plan Check 0.0 1 lirs
Water Heater
1PRWHEATR
1
#
$29
J. sr
F-1 I
Other Plumb Insp. LL.0jhrsL$48-00
L1 I
: 6<;:2..rr1.SZi.: c'e.:
I s«1Fs,i,..Z i'"�.:. ss,
$29.00
h,,sp.
F(.;f;:
F
Administrative Fee: IADAIIIN
$45.00
Work Without Permit? 0 Yes (@ No
$0.00
TOTALS:
'A
Travel Documentation Fee: I TRA VDOC
$29.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to -other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
61
Distri-t etc) Thova fppy are based nn the nreliminary information available and are onlv an estimate. Contact the Dept. for addn'l info.
FEE ITEMS (Fee Resolutior) 1.1-053 Lff. 7/1113f
FEE
QTY/FEE
MISC ITEMS
Plumb. Plan Check 0.0 1 lirs
$0.00
Fib.`c�.::h. penni-, Pee:
Plumb. Permit Fee:
—
IPPERMITI
J. sr
F-1 I
Other Plumb Insp. LL.0jhrsL$48-00
L1 I
: 6<;:2..rr1.SZi.: c'e.:
I s«1Fs,i,..Z i'"�.:. ss,
$29.00
h,,sp.
F(.;f;:
NOTE: This estimate does not include fees due to -other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
61
Distri-t etc) Thova fppy are based nn the nreliminary information available and are onlv an estimate. Contact the Dept. for addn'l info.
FEE ITEMS (Fee Resolutior) 1.1-053 Lff. 7/1113f
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee-
$29.00
PME Permit Fee:
$48.00
F
Administrative Fee: IADAIIIN
$45.00
Work Without Permit? 0 Yes (@ No
$0.00
A, , I
'A
Travel Documentation Fee: I TRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldgy Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$171.50
TOTAL FEE:
/$171.50
Revis : 10/01/72015)