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14010056 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 5991 BOLLINGER RD CONTRACTOR:ALLSTAR PLUMBING PERMIT NO:14010056 OWNER'S NAME: HARRIS AMY L TRUSTEE 326 PHELAN AVE DATE ISSUED:01/08/2014 O ER'S PHONE: 4085044622 SAN JOSE,CA 95122 PHONE NO:(408)230-5569 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E] ?�o -1),Lb�� REPLACE(E)40 GAL WATER HEATER,SAME LOCATION License Clas ^ s cj"�( t Lic.# j Contractor J"''1 1r t a Date e� I hereby affirm that I am licensed unde•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:$2270 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:37535025.00 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 WITIIIN 180 DAYS T 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 D ALLED 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 ( g 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: Signature Datel/0 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 thisOwner or authorized agent: i L1 Date �G 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 Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION 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. 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 X� GENERAL PERMIT APPLICATION MEPO`� COMMUNITY DEVELOPMENT DEPARTMENT-.BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 (408) 777-3228-FAX(408)777-3333-building(a)cupertino.org l� MISC 'JZL PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS Q I , A �O APN# 37- 5 - 3 0 OWNER NAME /�n �I' �l�f PHONE4te �-6q- qo.ZE-MAIL STREET ADDRESS 15j` q/ CITY, STATE,ZIP ��� n^ t ©/G/ FAX CONTACT NAME 7/ a` PHONE�bO_ 7 3-?r E-MAIL STREET ADDRESS .12/ CITY,STATE,ZIP 0 4 9�r-1119 FAX ❑ OWNER ❑ OWNER-BUILDER OWNERAGEAT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTORNAME ` LICENSENUMI: LImTYPZ/lV BUS.LIC 4) z IQ COMPANY NAME/_`/✓I'c/�t STREET ADONE DRES 2/ G/N/kP_�r �� CITY,STATE(, h�� PH�O� rl_bogo ARCHnWT/ENGINEER NNAME/,`` LICENSE NUMBER 7 BUS.LIC k T COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BU : F1ILDINGCOMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZANE ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK fLc�eLvcL c��.c �r 41tq .,_ �:x n f TOTAL VALUATION': yQ By my signature below,I certify to each of the following: I am the property owner or authorized ag nt to act on the property owner'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 building construction. I authorize representatives of Cupertino to enter the abovc-oentifie4 property for inspection purposes. Signature of Applicant/Agent: Gku, Date: 6 t/ SUPPLEMENTAL INTFOR14ATION REQUIRED of iIs WIN - - N. x w kE v �` STANDARD LARD _ g - MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 5991 BOLLINGER DR DATE: 01/08/2014 REVIEWED BY: MELISSA APN: 375 35 025 BP#: *VALUATION: $2,270 %PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY [PENTAMATION PRWHEATR USE: SFD or DuplexRMIT TYPE: WORK REPLACE E 40 GAL WATER HEATER SAME LOCATION SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $28 TOTALS: k :;' $28.001 F v ,We('11. Plein Check Plumb.Plan Check 0.0 his $0.00 Elec.Plan Check Lleclt.Pernail Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit Fee: Other;1kxh.Insp. Other Plumb Insp. 0.0 hrs $47.00 011ier Elec.Insp—E1F-1—. .t tech. Insp.Fee: Plumb. Insp.Fee: Elec.Insp I'ee: NOTE:This estimate does not include fees due to other Departments(i.a Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prefindnid information available and are only an estimate. Contact the Dept for addn'1 in o. FEE ITEMS(Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS Plan Cheep Fee: Suppl. PC Fee PME Plan Check: $0.00 Perinit.Fee: Suppl. Insp Fee PME Unit Fee: $28.00 PME Permit Fee: $47.00 Cont-fiction Tar: Administrative Fee: 1ADMIN $44.00 Work Without Permit? ®Yes 0 No $0.00 ,Idvuncec/Planning Fees: Travel Documentation Fee: 1TRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 F . $0.00 TOAL $16750 FSE $167.50 n Revised: 01/01/2014