14080234 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19722 BIXBY DR CONTRACTOR:DE ANZA BUILDERS PERMIT NO: 14080234
OWNER'S NAME: TAI FENG JOHNSON 1129 LITTLE JOHN WAY DATE ISSUED:08/25/2014
OWN
ER'S PHONE: 4088887967 SAN JOSE,CA 95129 PHONE NO:(408)865-0222
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
COPPER REPIPE
License Class
Contractor a,r.t.. ��iLd�r'S Date tS
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
ompensation,as provided for by Section 3700 of the Labor Code,for the
p rformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$7000
ave and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:36909020 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is pERlyII IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WIT 180 DAYS ERMIT 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 DAY LAST CALLED INSP CT N.
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:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point sou a ulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date —La 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 equi ment 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 A ea Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cup t o Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25 5 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:I�'"Zs"1`�
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 herebyauthorize 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
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CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
F9 ADDRESS: 19722 bixby dr DATE: 08/25/2014 REVIEWED BY: Mendez
APN: BP#: "VALUATION: $7,000
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION 1 RPRP
USE: SFD or Duplex PERMIT TYPE:
WORK co er re-pipe
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Re-Pipe Interior 1PRREPIPE 1 # $14
TOTALS: $14.00
g
FOE
-01111
Plumb.Plan Check 0.0 hrs $0.00
;4fe>�z Fee: Plumb.Permit Fee: IPPERMIT hie",.-_ Permit
i'h c fir, hq.T Other Plumb Insp. 0.0 �hrs $48.00 Oib?',1 <'. tsp.
NOTE: This estimate does not include fees due to other Departments(i.e.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 Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13) FEE QTY/FEE MISC ITEMS
I'laN ('h,,(:k /4:m:
771
PME Plan Check: $0. 0
0
PME Unit Fee: $14.00
PME Permit Fee: -F7E: $48.00
Administrative Fee: ]ADMIN $45.00
Work Without Permit? ® Yes (F) No $0.00
Travel Documentation Fee: ITRA VDOC $48.00 i
Strom Motion Fee: ]BSEISMICR $0.91 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
1
' iT $156.91 $0.00 TOTAL FEE: $156.91
s 6, - -
Revised: 07/10/2014