The URL can be used to link to this page

12010125 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21350 SERENO CT V26 CONTRACTOR:JESSUP PLUMBING INC PERMIT NO: 12010125 OWNER'S NAME: BERTHOLD,JOHN R TRUSTEE ASSIGNEE PO BOX 2038 DATE ISSUED:01/t9/2012 OWNER'S PHONE: 6»03221537 SAN LEANDRO,CA 94577 PHONE NO:(510)357-0525 13 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ' ELECT PLUMB �-7 License Class-_ 3,�, Lic.# S_c MECH RESIDENTIAL COMMERCIAL Cootracto Date I hereby affirm that I at licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL NEW GAS LINE FOR EXISTING FIREPLACE (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 t6r 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:$800 1 have and will maintain Worker's Compensation Insurance,ts provided for by Section 3700 of the Labor Code,t6r the performance of the work for which this permit is issued. APN Number:34255011.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indervinit!-v and keep harmless the City of Cupertino against liabilities,judgments, t80 DAYS FROM LAST CALLED INSPECTION, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations,per the Cupertino Municipal Code,Section Issued by: Date: SignatureDate ml /t-+,-- oe L RE-ROOFS: El OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7 044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation.as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,Inc the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Owner o utbor*zed agent: Compensation laws of California. If,after making this certificate of exemption,I Date:— become subject to the Worker's Compensation provisions of the Labor Code,I r%pr forthwith comply wide such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY i I hereby affirm that they _,Sonstruction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property v for inspection purposes.(We)agree to save indemnify and keep han-nless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulatims per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34255011. 00 DATE ISSUED. . . . . . . : 01/19/2012 RECEIPT #. . . . . . . . . : BS000015787 REFERENCE ID # . . . : 12010125 SITE ADDRESS . . . . . : 23350 SERENO CT V26 SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BERTHOLD, JOHN R TRUSTEE ASSIG ADDRESS . . . . . . . . . . : 23350 SERENO CT V26 CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MARK A HANKINS CONTRACTOR . . . . . . . : SCOTT JESSUP LIC # 33260 COMPANY . . . . . . . . . . : JESSUP PLUMBING INC ADDRESS . . . . . . . . . . : PO BOX 2038 CITY/STATE/ZIP . . . : SAN LEANDRO, CA 94577 TELEPHONE . . . . . . . . : (510) 357-0525 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1 .00 41.00 0 . 00 41.00 0.00 1BCBSC VALUATION 800 .00 1.00 0 . 00 1.00 0.00 1BSEISMICR VALUATION 800 . 00 0 .50 0 .00 0 .50 0.00 1PGASRES OUTLETS 1 .00 65.00 0 .00 65 . 00 0.00 1PPERMITFE FLAT RATE 1 .00 44 . 00 0 .00 44 .00 0.00 1TRAVDOC FLAT RATE 1.00 44 . 00 0. 00 44 .00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT : 195 .50 0. 00 195 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 195 . 50 DISCVR --------------- TOTAL RECEIPT 195 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 23350 sereno ct.#26 DATE: 01/17/2012 REVIEWED BY: bob s. .7" APN: BP#: VALUATION: 1$800 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION I RPGAS USE: JPERMIT TYPE: A WORK install new as line for existing fireplace. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $65 TOTALS: $65.001 Plumb.Plan Check O.OThrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. Loi hrs $44.00 Lj jVOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These.Lees are based on the L!relinjina information available and are only an estimate. Contact the De wfor addnl info. FEE ITEMS Lt,11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Pert-nit? 0 Yes (j) No $0.00 Travel Documentation Fee: I T&4 VDOC $44.00 sero wm--------tvlohior. IBSELMCR $0.50 Select an Administrative Item ---—.......... Bl ' (-'4 n- fissionFeeIBCBSC $1.00 ESUBTOTALS: 1 $195.501 1$0.001L::: TOTAL FEE: 1 $195.501 Revised: 1/01/2012 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# tl OWNER'S NAME: PHONE# GENERAL CONTRACTOR: '< ,� -';' J , - BUSINESS LICENSE# ADDRESS: =, `' ` l' � k l/-,/ TY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUP,ERTINO BUSINESS LICENSE. `~ I am not using any subcontractors: '�� Signature Date Please check applicable subcontractors and complete the foil�i g information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum/Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile / i v Owner/Contractor Signatu a Date AT RANCHO SAN ANTONIO January 18th, 2012 City of Cupertino 10300 Torre Avenue Cupertino, Ca 95014-3255 Attn: Building Division To Whom It May Concern: Jessup Plumbing, Inc has been approved to provide a new gas line to the existing fireplace at 23350 Sereno Court#26. The Forum at Rancho San Antonio is located at 23500 Cristo Rey Drive in Cupertino CA. Please provide them access to the permit for 23350 Sereno Court #26. Your assistance and cooperation is greatly appreciated. If you should have any questions please feel free to call me. Sipf erel 1� y (l1l Fred Hernandez 23500 Cristo Rey Drive, Cupertino, California 95014 • Tel 650-94/40100 • Fax 650-903-5920 • www.theforum-seniorliving.com RCFE#: 435200344 LJ COA#174 GENERAL PERMIT APPLICATION MEP La COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333- building(a.cupertino.orq MISC CUPERTINO PLUMBING ❑NfECHA ICAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS AFN# Dt OWNER NAME _ PHONE C_ ` E-MAIL STREET ADDRESS „ _ 7 , CITY, STATE,ZIP ' ! ,p •� FAX CONTACT NAME PHONE E-MAIL STREECADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUIIDER ❑ OWNER AGENT W CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME. r LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAMED E-MAIL FAX STREET ADDRESS n l CITY,STATE,"!SW LC Q ` (i 7 ARCHTTECTIENGINEER 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 WII DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: �� RECEIVED BY: By my signature below,I certify to each of the fo ng. 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 ect. h 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 c nstrucn "I auth 'ze representatives of Cupertino to enter the above-i tiffieed pro erty for inspection pu{poses. Signature of Applicant/Agent: Date: SUPtENENTAL INTO :njQ=D OFFICE USE ONLY t_l OVER-THE-COUNTER e. ❑ EXPRESS Y U ❑ STANDARD U ❑ LARGE a ❑ MAJOR MEPMrscApp 2011.doc revised 06121111