12090222 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 984 WESTLYNN WAY CONTRACTOR:MASTERSERV INC PER\IIT NO: 12090222
OWNER'SNAME: WARREN MINE TRUSTEE 560 LIBRARY ST DATE ISSUED:09262012
OWNER'S PHONE,: 4088022867 SAN FERNANDO,CA 91340 PHONE NO:(800)806-7674
LtY LICENSED CONTRACTOR'S DECLARATION •1011 DESCRIPTION: RESIDEXTIAL 11 COMMERCIAL
IJ
License Class I Lic.9 f2 b La�� REPIPE DOMESTIC WATER SUPPLY TO MAIN COPPER
Contractor l�'145+-e✓'S-eyy Date REPAIR
hereby affirm that 1 an,licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business S Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
1 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 pemit is issued Sq.Ft Floor Area: Valuation:514150
1 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
AI'N Number:35927012.00 Oceupancy'1'ype:
permit is issued.
APPLICANT CERTI FIC TION
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 Imus relating WITHIN 0 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 F OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilides,judgmcnts,
costs,and expenses which may accme against said City in consequence of the
grouting of this permit. Additionally,the applicant understands and will comply Issued by: `1� Date:
with all non-point source regi lations per the Cupertino Municipal Code,Section
9.18.
RF-ROOFS:
Signatuo,--fac, - y Date - All roofs shall be inspected prior to any roofing material being installed.If a roof is
�. installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ OWNIiR-BUILDER DECLARATION
Signature of Applicant: Date:
hereby affirm that 1 nm exempt from the Conlnaetor's LicenseLaw'for one of
the flllmring two reasons: AL1,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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. [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(0)should 1 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 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 Ilealth&Safety Code,Sections 25505,,25/533,ond25534.
Section 3700 of the Labor Code,for the performance of the work for which this fl./ p//
permit is issued. Owner or authorized agent: 8 ver wI2N 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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is o construction lending agency for the performance of
forthwith comply with such provisions or this pemnit shall be deemed revoked. w'ork's for which this pemnit is issued(Sec.3097,Cir C.)
Leader's Name '
AI'1'I,ICAN7'CER'I'IFIC,\'PION 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 re lotions per the Cupertino Municipal Code,Section Licensed Professional
9.18. y
Signature Dmc L—LL-1
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
hS: 984 WESTLYN WAY DATE: 09/2612012 REVIEWED BY: SYLVIA
BP#: 'VALUATION: $14,150
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARYPENTAMATION
USE: SFD Or Duplex PERI%IITT%'PE: Al
1RPR
WORK REPIPE DOMESTIC WATER SUPPLY TO MAIN COPPER REPAIR
SCOPE
Meeh. Plan Check Plumb. Plan Check 0.0 hrs $0.00 F.lec.Plan Check
Meeh. Permit Fee: Plumb. Permit Fee: IPPERMIT F.le.c.Permit Fee:
Other Mech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Eler.Insp. Ll
,Ilech. Insp. Fee: P/umh. last. Fee: Elec.Insp. Fec:
NOTE: This wtimate doer tint include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Seaver District,School
District, etc.). These feav are baser/on the relinninaninformation availahle and are only an estimate. Contact the Dept for addn'I into.
FEE ITEMS (Fee Resohuion 11-053 Ell 7/1/1/) FEE QTY/FEF I MISC ITEMS
Plan Check Fee: $0.00 1 # Plumbing
Suppl. PC Fee: Q Reg. Q OT FO.0hrs $0.00 $13.00 IPRREPIPE I Re-Pipe Interior
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Consi mclion Tax:
Administrative Fee: ]ADMIN $42.00 O
Work Without Permit? Yes Q No $0.00 0
Advanced Planning Pec: $0.00 Select a Non-Residential Q
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure
A
Strong Motion Feel IBSEISA11CR $1.42 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $134.42 $13.001 TOTAL FEE: $147.42
Revised: 07101/2 01 2
GENERAL PERMIT APPLICATION M E r
COMMUNITY DEVELOPMENT DEPARTMENT t BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 ((�� w'aa(IA I
CUPERTINO (408)777-3228 t FAX(408)777-3333 t bulldlnOLr)'CUDerIno.Oru tj(�
SC
PLL"MBING ❑MECHANICAL ❑ELECTRICAL I]HISCELLANEOUS
PROTECTADDRESS 1 . (A ),2,4(\/;Vl W VI I Ap35q ; 'j v a
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OWNER NAME
-SiREETADDRESS , GTTY, ATE,IIP rl d 3l9 / FAX
avaCosEhe 4� Jas , c, f-03u
CONTACT NAME PHONE I E-MAIL
STREET ADDRESS CITY,STATE, Zr? FAX
OWNER ❑ OW7.T.A-BL DER ❑ MlrER AGENT EI CONTRACTOR ❑CONTRACTOR AGSM ❑ ARCHrTECT ❑ENGWEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME LICENSENUMBr�x LICENSE TYPE BUS.LIC#
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�COWANY NAME E MAfL1 FAX
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STREET ADDRESS / IMe,STATE,Z[P / I !n PHONE
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ARCHMMENG]NEFR NAME LICENSE NUMBER / I BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS I CITY,STATE,ZIP I PHONE
USE OF O SFD m DUPLEX ❑ MULTI-FA Y PROJECT W wrLDI.O.D 0 YES PROJECT N ❑YES I IS THE BLDG AN ❑
H. ES
BUDDIG: M - CIAL
CORURBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME7 Cl❑ NO
DESCR FIION OF WORK
)^r lA No d-i lI✓\ 'J') WA4W1_ '
�\e i( D B c )•Vzr rel I:'i �( / '
STOTAL VALUATION: X11 LI, I Sv I
RECEIVED BY:
By my signaturc below,I certify to cath of the following: I am the property owner or authorized agent to act on the. r,m owner's behalf. I have read this
applicaion and the in`ormaaon I bave provided is cotrett. I have read the Description of Work and veriry i;is accurate. agregto comply with all applicable local
ordinances and sate laws relating m building consmucc �� II,a�u�thypme representatives o:Cupertino to enter the above-identified property for inspection putposes.
Signature of Applicant/Agent: /lv!/1 T/us-- Date: "1- /-l:'�
SUPPLEMENTAL INFORMATION REQUIRED FICE USE 0'%Ly
OVER-THE-COUNTER
Y
- ❑
EXPRESS
75
❑ STANDARD
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< ❑ LARGE
❑ MAJOR
MEPMucApp_2011.doc revised 06/21/11