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13090225 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22648 SILVER OAK LN CONTRACTOR:JAMES CHAPMAN PERMIT NO:13090225 CONSTRUCTION OWNER'S NAME: FRAN TURBOK 4196 MONET CIRCLE WAY DATE ISSUED:09/30/2013 OWNER'S PHONE: 4087616154 SAN JOSE,CA 95136 PHONE NO:(408)309-1907 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT F_ PLUMB r- License Class Lic.# q60 LZ MECH RESIDENTIAL COMMERCIAL Contracto>J�'V`'+wS �/�/iriyVs.,,�1te � � � � I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPAIR GAS LINE NEXT TO CHIMNEY BEING REPAIRED (commencing with Section 7000)of Division 3 of the Business&Professions Cod and that my license is in full force and effect. I reby firm under penalty of perjury one of the following two declarations: rid will maintain a certificate of consent to self-insure for Worker's mpensation,as provided for by Section 3700 of the Labor Code,for the erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$135 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 permit is issued. APN Number:34249001.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Q with all non-point source r ns per the Cupertino Municipal Code,Section Issued by: �'i4/✓ Date: 9.18. Signature Date t7 V3 RE-ROOFS: ❑ NER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) y, I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Coad,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner or auth ' n •- Compensation laws of California. If,after making this certificate of exemption,I Date: 3'O f 3 become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. e CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date 100q oe;2.?s GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINd (408)777-3228• FAX(408)777-3333•buildlnclCEDcupertino.Org MISC CU*LUMBING ❑MECHANICAL ❑ELECTRICAL FIMISCELLANEOUS �� PROJECT ADDRESS t 7 t „(� t J? APN if OWNER NAME 7^ e� e-C\ PHONE .^ ` E-MAIL ...,, STREET ADDRESS 6` v ��V`CITY, STATE,ZIPP v �� FAX CONTACT NAME ` S (�,(_ M a1^ PHONE '-,.[ E-MAIL STREET ADDRESS J V\ ``\ CITY,STATE, -ZIP` FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMB LICENSE TYPE BUS.LIC# � C�Gc'mA COMPANY NA E-MAIL FAX O r') k�0r\ I aM t.5 0, WdA,v- STREET ADDRESS ^ ` , �C u CITY,STATE,ZIP PHONE r ARCHITECT/ENGINEER NAME N LICENSE NUMBER BUS.LIC# l COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP ti PHONE USE OF or DUPLEX ❑ MULTI-FAMILYPROJECT IN WI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN YES BUILDING: COMMERCLII. URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLER HOME? O DESCRIPTION OF WORK S o lsiw TOTAL VALUATION.A t3 RECEDBYr �� ' a By my signature MR,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building ct' . au oriz entatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Appl icant/Agent: Date: 3 b i J SUPP?K4ENTAL INFORMATION WUIRED y q Or x Z EXPRESS 1 NFIEVINSMORM MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22648 Silver Oak DATE: 09/30/2013 REVIEWED BY: Sean APN: BP#: *VALUATION: $135 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPGAS USE: p PERMIT TYPE: WORK Repair gas line next to chimney being repaired. SCOPE APPLIANCE/EQUIP TYPEFEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 0 # TOTALS: $0.00 ! i a .Meeh. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec:.Plan{.heck Tech.Permit Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit Fee: [h. Nfech.Insp. Other Plumb Insp. 0.0 hrs $47.00 Other Elee.Insp. ILIcInsp. Fee: Plumb. hasp. 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). These fees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS(Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC 1"ee PME Plan Check: $0.00 Permit.Fee: Suppl. Insp Fee PME Unit Fee: $0.00 PNM Permit Fee: $47.00 Consiruction Tax: Administrative Fee: /ADMIN $44.00 Work Without Permit? ® Yes Q No $0.00 Advanced Planning Fees: Travel Documentation Fee: 1TRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC 1 $1.00 $139.50 $0.00 $139.50 KR 5 O Revised: 08/01/2013 10 T-�;b