12110099 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19409 PHIL LN CONTRACt'OR:711ANGS BUILDING CO PERMIT NO: 12110099
OWNER'SNAME: JANE IIUEY-CFIYN 2175 UNIVERSITYAVE -DATE ISSUED: 11116/2012
OWNY.FI'S PIIONTE: 4086148900 MOUNTAINVIEW.CA 94040 PHONE NO:(650)450-0680
LI&NNSED CON TRACT-OfR''S DECLARA'T'IONgU1LDINC PERMIT'INFO: BLDG r ELECT❑ PLUMB (J
License Class S Lic.9 g 6 r r, C
/1 MECFI RESIDENTIAL COMMERCIAL
Contractor �P.f7Q_ C nn Date // -(6 7�
I hereby affirm that I am licensed under the provisions of Chohpter 9 JOB DESCRIPTION:REMOVE AND REPLACE WALL I]EATER
(commencing with Section 7000)of Division 3 of the Business& Professions
Code and that mi license is in full force and effect.
hereby affirm under penalty of perjury one of(he following two declarations:
I have and will maintain a cenificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$600
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
.U'N Number:37505033.00 Oceuphmcy Type:
\I'I'LICAN"1'CEIf1'I FIC.\'PION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM L CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands mid will comply
with all non-point source regulations per the Cupertino Municipal Code,Section /
9.18. Issued by: �` v Date:
Signature //' —C' // Date
❑ OWN17.14-BUILDFI2 DECLARATION RF.-ROOFS:
All roofs shall be inspected prior many rooting material beimg installed.If a roof is
I hereby affirm that 1 am exempt tram the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: - - inspection.
I,as owner of propeny,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, Signature of Applicm: Done:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contmcmrs to
construct the project(Sec.7044,Business&Professions Code). AL1.ROOF COVERINGS TO BE CLASS"A"OR 13E'I'1'FR
hereby affirm under penalty of perjury one of the following three
declarations: IIA7.ARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements tinder Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Cade,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Iiealth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code.Section 25532(x)should I store or handle hazardous material.
Section 3700 of Labor Code,for the performance of the work for which this Additionally.should 1 use equipment or devices which emit hwardous air
contamin:m is as defined tw the Bay'Area Air Quality;Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of die work for which this permit is issued,I shall Ilealth&Safety Code.Sections 255115,25533,and 25534.
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 Owner or a orae age y
become subject to the Worker's Compensation provisions of the Labor Code,I must Date.
forthwith comply with such provisions or This permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
\PPLICANI'CI:R"1'IFICA'I'ION 1 hereby affirm that there is a construction lending agency for the performance of lwrk's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city,and county ordinances and state lases relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harndess the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of ARCIII'TEC'I"S DECLARATION
grating of this permit.Additionally,the applicant understands and will comply
with all nori-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
SignatureDale
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 19409 phil In DATE: 11/16/2012 REVIEWED BY: larrys 74
APN: 375-05-033 BP#: 'VALUATION: $0
*PERNIIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTANIATION FURN/AC
USE: PERNUIT TYPE:
WORK
SCOPE
APPLIANCE'/EQUIP TYPE FEE ID QTl' UNITS BP FEES
Heater, Recessed Wall 1MRSUSHTR 1 # $67
F-
'IOTA LS: $67.00
Mech. Plan Check 0.0 1 hrs $0.00 Plumb.Plan Check flee.Plan Check
Mech. Permit Fee: ImPERAUT Plumb. Permit Fee: F:lec•.Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp. Other Elec.InsP.
Hech.limp. Fee: Plumb. htxp. Fee: Elco.Insp. Fec: .
NOTE: This estimate does not inclutlejeev due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Saver District,School
District,etc. . These eav are based on theirrelitninari information arnilable and are only an estimate Contact the Dept for addis'I info.
FEE ITEMS (Fee Resolution 11-053 Ea LL/JJ2 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Supp/. lisp Fee
PME Unit Fee: $67.00
PME Permit Fee: $45.00
Construction Tin:
Administrative Fee: (ADMIN $42.00
:Work Without Permit? 10 Yes 10 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAI'DOC $45.00
A
Su'ong Motion Fee: $ Select an Administrativgjtem(:)
Blde Stds Commission Fee: $0.00 4Z10
SUBTOTALS: $199.00 $0.00 TOTAL FEE: $ ,00
Revised: 10/01/2012
GENERAL PERMIT APPLICATION M E P
- � COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ,
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 ! >� ,
CUPERTINO (408) 777-3228 • FAX(408)777-3333• buildina(cDcuoertino.ora e
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(TOTAL VALUATION: RECEIVED BY:
By cry signaoae below,I cerdfy to each o'thc-.ollcvr ng: I ata:he pmoeay owner o;wm- onzed agent to act,on the ptopery cv.s's behalf. I have read this
appliun:on aid the into-aticn I have provided is COITeCL I have rezd Lie Desmiptioo of'Work and vcri3'it is accurz;c. I zgce:o comply with all zonlicable local
ordinances rad state laws tnlzting tobuilding cens�octio;,. I znLio_4 sepr_sentadves o`Camino to enmr Lhe above-idead5e3'psnpry for inspecdoa pv'poses.
Sigaamre of Applicant/Agent: Dare:
SL-PPLEbCN 1 A L?NYORMATION REQU1-RED OFFICE USE ONLY
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ACP.>, uc4pp_20J 1.doc revised 06/21/11