The URL can be used to link to this page

12020043 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 941 MILLER AVE CONTRACTOR:WATER QUALITY PERMIT NO: 12020043 PLUMBING OWNER'S NAME: BUCHHOLZ, LYNN 1860 ALMADEN RD DATE tSSUED:02/09/2012 OWNER'S PHONE: 4082472882 SAN JOSE, CA 95123 PHONE NO:(408)267-9330 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB f License Clas C Lic.#:��j�� ) � MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION: REPLACE WATER HEATER AND COPPER RE-PIPE 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. 1 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:$4300 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:36919049.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION (:;001 1 -- 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 rtM LAST CALLED INSPE T N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: G Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signattwe `� Datef/ 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) 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 1 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 1 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,Sectio -2;-0-5;,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ager • Dater 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I 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 CITY OF CUPERTINO 7 ITEMS OF 13 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36919049 . 00 DATE ISSUED. . . . . . . : 02/09/2012 RECEIPT # . . . . . . . . . : BS000015974 REFERENCE ID # . . . : 12020043 SITE ADDRESS . . . . . : 941 MILLER AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BUCHHOLZ , LYNN ADDRESS . . . . . . . . . . : 941 MILLER AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4661 RECEIVED FROM . . . . : LYN SATALINO CONTRACTOR . . . . . . . : SATALINO, MARTY LIC # 21526 COMPANY . . . . . . . . . . : WATER QUALITY PLUMBING ADDRESS . . . . . . . . . . : 1860 ALMADEN RD CITY/STATE/ZIP . . . : SAN JOSE, CA 95123 TELEPHONE . . . . . . . . : (408) 267-9330 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 8, 600 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 8 , 600 . 00 0 . 86 0 . 00 0 . 86 0 . 00 1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1PRREPIPE NO OF FIXTURE 1 . 00 12 . 00 0 . 00 12 . 00 0 . 00 1PRWHEATR UNITS 1 . 00 26 . 00 0 . 00 26 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 168 . 86 0 . 00 168 . 86 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------------------------ 518 WATER HEATER CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 941-9+ Iler Ave. DATE: 02/09/2012 REVIEWED BY: jsg APN: BP#: VALUATION: Iso PERMIT TYPE: Plumbing Permit =PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPRP USE: I PERMIT TYPE: WORK Copper re i e of duplex, two water heaters SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Re-Pipe Interior 1PRREPIPE 1 # $12 Water Heater 1 PRWHEATR # TOTALS: 1 $64.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs71 $44.00 NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public FVorks,Fire,Sanitary Sewer District,School District,etc.). These ees are based on the relinina in ormation available and are onlyan estimate. Contact the De t or addn 7 in o. FEE ITEMS ( g� t� .d/d�4> 1 �'5 �I :3' A FEE (QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $64.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Pen-nit? 0 Yes 0 No $0.00 Travel Documentation Fee: I TRA VDOC $44.00 trow, t�:lof;or5 Fee- $0.00 Select an Administrative Item ,",{1 e C �g $0.00 SUBTOTALS: $193.00 $0.00 TOTAL FEE: 93.00 Revised: 1/19/2012 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX(408)777-3333• building(d)-cupertino.org MISC t2.,02()0q3 NEOUS I M AgPLUMBING ❑MECHANICAL ELECTR CAL ISCELLA PROJECT ADDRESS I t APN# , ^ w � W OWNER NAME / SaC,nA PHONE D _ � E-MAIL ao STREET ADDRESS Gj • CITY, STATE,ZIP C.��-��r L� FAX CONTACT NAMEPHONE E-MAIL R - �7'< � , 1 STREET ADDRESS 41 j X_\ j�j CITY,STATE, ZIP FAX - go� r (✓ ❑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 F 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 JffSFD or DUPLEX MULTI-FAMILY PROJECT 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 eo�11 . TOTAL VALUATION: J� Cl 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 buildino construction. I authorize representatives of Cupertino to enter the abov -ide tid property for inspection purposes. Signature of Applicant/Agent: �!'- �" Date: , SUPP MENTAL INFORMATION REQUIRED OFFICE USE ONLY FA ❑ OVER-THE-COUNTER a ❑ EXPRESS U ❑ STANDARD U a ❑ LARGE a ❑ MAJOR MEPMiscApp_2011.doc revised 06121/11