13070021 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10411 E ESTATES DR CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 13070021
OWNER'S NAME: SPARKS JACK L AND MARIE S 7020 COMMERCE DR DATE ISSUED:07/03/2013
OWNER'S PHONE: 4152534491 PLEASANTON,CA 94588 PHONE NO:(925)4444444
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL❑
License Class 7i(� Lic.# q'(7`0`Z REPLACE 10 SUPPLY DUCTS&2 RETURNS
Contractor iU Date Z'2-13
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.
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:$5235
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:36913045.00 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 and county ordinances and state laws relating WITIIINgFROST
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 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 Issued by Date: 3
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date ` 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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.1044,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 9.12 and 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 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 I
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,Sec o s 25505,255 ,and 25534. 12
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen Date: ` ✓`J
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 ARCHITECT'S DECLARATION
indemnify and keep harmless 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
9.18.
Signature Date
GENERAL PERW APPUCAMN /1/1MEP
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10414 E ESTATES DR DATE: 07/03/2013 REVIEWED BY: MELISSA
APN: 36913 045 BP#: *VALUATION: 1$5,235
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RMAP
USE: PERMIT TYPE:
WORK REPLACE 10 SUPPLY DUCTS &2 RETURNS
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 113APPLOT 1 # $70
TOTALS: $70.00 =.
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Mech.Plan Check 0.0 hrs $0.00 Phinrb.Plan Check Dec.Plan Check
Mech.Permit Fee: 1MPERMIT Plumb.Permit Fee: Llec, Permit Tee:
Other Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp. LLJ Other flee_Insp.
_llech. Insp. l'ee: Plumb.Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(ie.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These ees are based on the relimina in ormation available and are onl an estimate- Contact the Det or addn'1 info,
FEE ITEMS (lee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS
Plein Check Fee:
slippl. I'C"Fee
PME Plan Check: $0.00
Permit Fee:
Suppl.Insp F'ee
PME Unit Feer $70.00
PME Permit Fee: $47.00
Construction 7 ax:
Administrative Fee: 1ADMIN $42.00
Work Without Permit? ® Yes (F) No $0.00
Advanced Plarming Fess:
Travel Documentation Fee: ITRAVDOC $45.00
Strong]Motion Fee: IBSEISMICR $0.52 Select an Administrative Item
Bldy Stds Commission Fee: IBCBSC $1.00
$205.52 $205.521
OR OTALFEE $205.52
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