12100211 (3) CITY OF CUPERTINO BUILDING PERMIT
RUILDING ADDRESS: 10310 BONNY DR CONT TACTOR:WATER IIEATERS ONLY PI.RMIT NO: 12100211
OWNER'S NAME: LAWVER DARELL J AND DIANE J 970 E NIA IN SI' DATE ISSUED: 10/302012
OWNER'S PIIONE: 4058651550 GRASS VALLEY.CA 95945 PHONE NO:(800)835-5946
❑ LICENSED CON'1'RACI'OR'S DECLARATION BUILDING PERIIIIT INFO: BLDG r ELECT(J PLUMB r
License Class Lie.q
M ECH r RESIDENTIAL 'J COMMERCIAL r_
--
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE WATER HEATER IN SAME
(commencing with Section 7000)of Division 3 of the Business&Professions LOCATION
Code and that my license is in full force and effect. 50 GAL
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 permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this Sq.Ft Floor Areu: Valuation:$1594
permit is issued.
APPLICANTCERT'I FICATION ANNNumber.35914046.00 Occupancy Type:
I certify that I have read this application and stale 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date Issued by: Date:
❑ OWNER-RIALIIER DECLARATION
RI:-ROOFS:
I hereby affirm that I am exempt from the Cunlractor's License Law formic of. All roofs shall be inspected prior to any rooting material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALI,ROOF COVERINGS TO BE CLASS"A"OR BF;ITF,R
hereby affirm under penalty of perjury one of the following three
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's ILA/,ARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of die Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California lleallh&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
I have omit will maintain Worker's Compensation Insurance,as provided for by com plin nee with the Cupertino Municipal Code,Chapter 9.12 and the I IealtIt&
Section 3700 of the Labor Code,for the performance of the work,for which this Safety Coda Section 2.5532(1)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Buy Area Air Qualily Management District I will
I certify that in the performance of the work for Which this permit is issued,1 shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilcalth&SafesCode,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate ofexemption,I
become subject to the Worker's Compensation provisions of Ilse Labor Code,I must Owner or nnlhorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Dare:
APPLICAN"I'CF:R'fIFIC.\"\'ION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm tura there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant mnderstands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section nRcurrer.rs DECLARATION
9.1 8. I understand my plans shall be used as public records.
Signature Dale Licensed Professional
Building Department
CITY OF CUPERTINO BUILDING PERMIT `
BUILDING ADDRESS: 7864 BELKNAP DR CON\fRACFOR:SAN JOSE PLUMBING PF,RNIIT NO: 12110071
INC
OWNER'S NANIF:,MARY GIRODO 19970 MCKEAN RD DATE. ISSUED'11/13/2012
OWNER'S PHONE: 4082577784 SAN JOSE,CA 95120 PRONE NO:(408)296-1820
.LICENSED CONTRACTOR'S DF,CLARATION JOB DESCRIPTION: RESIDE\PIAL U COMMERCIAL
License Cli Lic.q COPPER RE-PIPE
Contractor.: - Date •I
1 hereby affirm that I am licensed under the provisions of Chapter 9 ,
(commencing with Section 7000)of 1)ivision 3 of the Business&Professiaas
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
performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation:$9044
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 APN Number:36210041.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify thin 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 cit}'to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA: LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the /1-13' r'7
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal C de,Section
9.18.
7 RE-ROOFS:
Signature Date J All roofs shall be inspected prior to any roofing material being installed. Ifo roof is
installed without first obtaining an inspection,I agree to remove all new materials for
v inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
hereby affirm.thal I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO 13E CLASS"A"OR BF,'1-I'ISR
1,as ownerof 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).
L as ownerpf the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have rend the hazardous materials requirements under Chapter 6.95 of the'.
• California Ilealth&Safely Code Sections 25505,25533,and 25534. 1 will
I hereby a' irm 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 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
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&Safete. cboo . .. 05,25533,and 25534.
O
Section 3700 of the Labor Code,for the performance of the work for which this /
wner or authorized ng nt: Dat)+:
permit is issued.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in nn)•manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRIICFION 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. works for which this permit is issued(Sec.3097,Civ C.)
;•.� - Lender's Name
APPLICANTCERTI FICATION Lender's Address
I certify that 1 have read this application and stale 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, ARCIIITFCT'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
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 7864 belknap dr DATE: 11/13/2012 REVIEWED Bl': mendez
APN: BP#: -VALUATION: 1$9,044
PERMIT TYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY SFD Or Duplex PENTAMATION 1RPRP
USE: PERMIT TYPE:
WORK copper re- i e
'SCOPE
'APPIAANCE7 EQUIP TYPE FEE ID QTY UNITS IIP FEES
Re-Pipe Interior 1PRREPIPE 1 # $13
TOTALS: $13.00
blech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Flee. Plan Chock
Mech.Permit Fee: Plumb. Permit Fee: 1PPERMIT Dec.Permit Fee:
Other,lle'c•h.Insp. ' LJ I Other Plumb Insp. 0.0 hrs $45.00 Other Elce.Imp.
Mech.hup. Fee: Plumb. tut).Fee: Me.hup.Fec:
NOTE: This estimate does not include fees clue to other Departments(i.e. Planning, Public II'ork,s, Fire,SanitarySerer District,School
District.etc. . These ees are based on the prelintinan information available and are onh,an estimate. Contact the De t or at/tbn7 in n.
FEE ITEMS(Fee Resolution 11-051 EB' 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Penni/Fee:
Supp/. lnsp Fee
PME Unit Fee: $13.00
PME Permit Fee: . $45.00
C'olistructiori Thr: .
Administrative Fee:' IADhaN $42.00
Work Without Permit? Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAPDOC $45.00
i
Strong MotionFee: leSE1SMICR $0.90 Select an Administrative Item
Bldg Stds Commission Fee: IeCeSC $1.00
SUBTOTALS: $146.90 $0.001 TOTAL FEE: $146:90
• Revised: 1 0101/2 01 2
GENERAL PERMIT APPLICATIONMEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION u
10300 TORRE AVENUE •CUPERTINO, CA 950143255 w w ' /� /�
CUPERTINO (408) 777-3228 • FAX(408)777-3333 • building rn.cuoertino.Ora \1 ,�„ '\v/' v\ \�"
PLUMBING ❑MECHANICAL ❑ELECTIUCAL 1❑\vMIS=c LANEOUS
Pxorr uDDREss �G�/ I AN
-
PHOT- (0n 16 G
OwNe�i. NAME ra d\ E-MAD-
S iZLEETADDRESS CTY, STATE,ZIP I FAX
CDNTALT N / r, PHONE
sTTzF—Ei.ADDREs G CITY,SATET .s/ FAX
❑ OWN-EX ❑ OwN=R-BUnn!JL ❑ OWNZRAG�.TC5KICONTRAC70R. ❑CONFRACTORAGEYF. ❑ ARCF,r ❑ :?+c]-�'t- ❑ DS=--OPER ❑ -Mv 7
CONTRACTOR NAME _ T
J S / LICENSE • LJCZNSE I BUS.LC 4
COMPANY NAME .� B-MAD.• FAX
S-r=ADDRESS/ CTY.STATE MP G / ( 2HONE �� /D ,
ARCr'CT/ENG1KSKkME I LICENSENUASME J/ I BUS.LICA
COMPANYNAME' I E-MAIL FAX
STREETADDRT_SS CITY,STATE IIP PHONE
USE OF CnM.DUPLEX ❑ MULTI-FA Y PROTECT IN WD.DLAND [I YES PROIECT IN ❑ m IS THE BLDG AN ❑ YES
SUILDLNG: E]cDNJ.OR L I URBAN ATERFACS AREA NO FLOOD ZONE ❑ NO EICHLR HOME? ❑ NO
DESC?,UMON OF WORK
TOTAL VALUAnc : 9 I RECEIVED BY:
Byrvy signzn:rc Belo ,I u Sfy:o Exch of:he following: Ian;be pmpc try owner or z_;horized agent to act on tl:e am owner's behalf. 1 have ud;his
application and the in`omarien I have pro'�i - corr CL I have read the Description of Work and verify a:o con ly with all applicable local
ordirmcm and sate laws relating to' ng con c=. 1 a + ori enadvcs of Cunerdno to enter Lhe above-iden'i/ed pmp .y for inspeeion pui' oses.
Signzan:of ApplicanyAgen' Dare: 3
SL EM:ENFAL TNFORM_ATION REQURED OFFIc ONLY
y OVER-THE-COUNTER
❑ EXPRESS
u
❑ STANDARD
U
at
< ❑ LARGE
❑ MAJOR
.A1ZJo wfuc4pp_2011.doc revised 06/21/11