13040132 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; 20034 NORTHWIND SQ CONTRACTOR: 13 4Y &X PERMIT NO:13040132
OWNER'S NAME::KIT CHUC DATE ISSUED:04/17/2013.
OWNER'S PHONE 4b89882799. PHONE NO:
❑ LICENS_ED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lica# jDC g REPLACE(E)40 GAL WATER HEATER,SAME LOCATION
Contractor4 YI ek3=4k�4.'� Date
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.mylicense 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:$1500
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:31638062.00 Occupancy Type:
permit is issued. .
APPLICANT CERTIFICATION
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 andlcounty 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 18O DAYS S CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses:wliich may accrue aga' t said City inconsequence of the Date
granting of this permi dditionally, applicant understands and will
comply I by:
with all non-point regulatio erthe Cupertino Municip Code Section
9.18.
�( I RE-ROOFS:
Signature Date l `� 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.
❑ OWN R=BUILDER DECLARATION
Signature of Applicant: Date:
I hereby'affirm;that:1 am:exempt fromilit Contractor's License Law for one of
the following two reasous. ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the properry,''or my,employees'wifh wages as their sole compensation,
will do tbe,work,,arld the structure is not intended or offered for sale(Sec:7044,
Business&,P1.rofessions Cooe) �
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. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equi went or dey)ces which emit'hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay ea Air ity Management District I .
Performance,of the work for which this permit is issued. will maintain compliance with the C rtino icI al Code,Chapter .12 a d
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 505, 33,and 25534. /� r
Section'3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:—t _7 t
permit is issued. '.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ zany person' nl,any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California.' It of terimaking 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 me tioned property,for inspection purposes.(We)agree to save
!� ARCHITECT'S DECLARATION '
indemnify and keep han4ess the City of Cupertino against liabilities,judgments,
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
Signature Date
GENERAL PERMIT APPLICATION MER
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �O
10300 TORREAVENUE•CUPERTINO, CA 95014-3255 O
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinct(a7cupertino.org
MISIC
PLUMB TING ` MECHANICAL ❑ELECTRICAL []MISCELLANEOUS
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PROJEC ADDRESS26
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CONTACT NAME PHONE E-MAIL
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❑ONRVER OWNER-BUILDER - D OWNER AGENT 1k CONTRACTOR 13 CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER 11DEVELOPER 13 TENANT
CONTRACTOR NA(v}E LICENSE NUMBE LICENSE TYP BUS.LIC#
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USE of!,,DUPLEX a MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑.YES .
BUII:.DING: ❑COMMERCIAL. ! URBAN INTERFACE AREA `!FNO FLOOD ZONE El NO EICHLER HOME? ❑NO
DESCRIPTION OF,woRlc Lb Iv 1n.N'k-T��
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'TOTAL VALUATIO :
By niy Signature below,I certify to each of the f ng: I am the pro owner or authorized agent to act on the property owner's behalf. I have read this
application and!;�he information I have provi correct. I have r e Description of Work and verify it is accurate. I agree to comply'with all applicable local:
ordJnancesland;state laws ielatmg to buil ' onstruction. I a rize representatives of Cupertino to enter the above-id tified roperty for inspection purposes ,
ra L
Slgnafurel ofiAp�hcant/Ager& Date:
SUPPLEMENIF hl
TAL INFORMATION REQUIRED
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MEPMiscApp_2011.doc revised 06/21/11
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CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
its ADDRESS: 20034 NORTHWIND SQ DATE: 04/17/2013 REVIEWED BY: MELISSA
APN: 316 38 062 BP#: *VALUATION: $1,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK REPLACE E 40 GAL WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $27
TOTALS: _ $27.00 s _
a
1<:ch.Ptah Check . Plumb.PlanCheck 0.0 hrs $0.00 Elee%Plan Check
"Wech.Permit Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit Fee:
FAfc'h.
h9ech:Insp. Other Plumb Insp. 0.0 hrs $45.00 OtherElec.Insp.Inah.Fee: Plumb. Insi).Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7ff 111121 FEE QTY/FEE MISC ITEMS
Plan Check Fee
Szpol. PC Fee
PME Plan Check: $0.00
Perinit Fee:
Suhpl. Insp Fee:
PN E,Unit Feer $27.00
P][!E,Permit Fee: $45.00
C��nstrztction :Tit:::
Administrative Fee: IADMIN $42.00
Work Without Permit? 0 Yes Q No $0.00
Adtiunred Planning Fees.
Travel Documentation Fee: 1TR4VDOC $45.00
Strohsz Fee. IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission.Fee: 1BCBSC $1.00
JIM 03 $160.50 $0.00 ' $160.50
�` • Revised: 04/01/2013