14030129 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10166 MC LAREN PL CONTRACTOR:ONE DAY COMPLETE PERMIT NO: 14030129
REPIPE
OWNER'S NAME: HATAMI MOHAMMAD H AND SUSAN D 617 N 12TH ST DATE ISSUED:03/21/2014
OWNER'S PHONE: 4084460802 SAN JOSE,CA 95112 PHONE NO:(408)603-0554
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
INSTALL 30 FT 1"DEDICATED GAS LINE FROM GAS
License Class Lic.# METER
TO NEW LOCATION FOR NEW TANKLESS WATER
Contrac Date HEATER
I 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:$3250
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:31621046.00 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 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 180 DAYS FRQN LAST CALLED INSP CTI?N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Date i
costs,and expenses which may accrue against said City in consequence of the Issued by:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
918.
RE-ROOFS:
Sig! atu 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.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 9.12 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,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized age Date:
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
918.
Signature Date
GENERAL PERMIT APPLICATION � M E P
COMMUNITY.DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•building8-cugertino.org
MSC
❑PLUMBING []MECHANICAL
❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADD SS C APN#,3r 2—t''(q 040-0 0
OWNTTERNAME PHO E-MAIL(°/
STREET AD RES CITY,STATE, 0 c ' FAX
C Y
C ACT N PHONE n E-MAIL
Woe
STREET DRESS STATE �( FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENTCTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTO AME LICENSE NUMBE LICENSE TYPE BUS.LIC#
33
COMPANY NAMaJ E-MAIL FAX
TTY,STATE Z PHONE ^
ARCHITECT/ENGWEERNAME ✓. LICENSENUMBER. BUS.LIC# u
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMII Y PROJECT IN WIIDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK p �!
'Led '�j F':
bl
TOTAL VALUATION: y. ` �
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property oAmer's behalf. I have read this
application and the information I have provided is correct. I 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 buil ' ction. Tauthorize re entatives of Cupertino to enter the above-identified prope for inspection purposes.
Signature of Applicant/Agent: Date: 3'
PLEMENTAL INFORMATION REQUIREDk rt;
a
STAND =[w�: us. r
= 11A 4'
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10166 mclaren pl DATE: 03/21/2014 REVIEWED BY: Mendez
APN: BP#: *VALUATION: 1$3,250
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Du lex PENTAMATION PRWHEATR
USE: p PERMIT TYPE:
WORK install 30 ft 1" dedicated gas line from gas meter to new location for new tankless water heater
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $28
Piping, Gas <=4 Outlets 1PGASRES 1 # $70
TOTALS: $98.00
, ; T
.a ... v
Plumb.Plan Check] 0.0 hrs $0.00 t =n
Plumb.Permit Fee: 1PPERMIT f;iec. I VA'
;Wc:h. hasp Other Plumb Insp. 0.0 hrs $47.00 Uthe; t �_1��t�.
E3
Phrrrth. Insp.Fee: }>tec Insp, P e
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 on! an estimate. Contact the Dept for addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 7!1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC:`]''ee
PME Plan Check: $0.00
5uppl. I71.sp 1:'eu
PME Unit Fee: $98.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
flf,?voi7c'e(I f 1171'i8 ing F£'E'V:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
00
e:
. $237.50 $0.00 TOTAL FEE:' $237.50
Revised: 01/15/2014