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15110123CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10566 S DE ANZA BLVD CONTRACTOR: AMERICAN PERMIT NO: 15110123 RESIDENTIAL SERVICES OF CA OWNER'S NAME: BYER PROPERTIES LP 965 RIDGE LAKE BLVD STE 201 DATE ISSUED: 11/18/2015 OWNER'S PHONE: 4085091575 MEMPHIS, TN 38120 PHONE NO: (408) 982-0405 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIALE] WATER HEATER REPLACEMENT AT SAME LOCATION License Clas ' 2 Lic. #' CO 1 S Contractor _'tIL'-S PA: i�C 4 V"fDateO l ( l 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 Sq. Ft Floor Area: Valuation: $1500 erformance of the work for which this permit is issued. 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: 36938037.10566 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 FROM LAST 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 t3 granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature*(_.�����Date#t j t' C1 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. 41k.Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: l 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 CUPERTIN0- GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 9501A 3255 (408) 777-3228 • FAX (408) 777-3333 • build! nC(a)OUDertlnO.Org U311131NG ❑ NiECH_A2�ZC.AL - �-=� =WMR ❑ELECTRIC . ❑b ISCELLANMEOUS PROJECT ADDRESS . I .AP?�' / —,-Yb b — 0 37 ,- O %QM NAlviz PHONE LlC)g REIT 3 �j �I� a- ��X '�'S STAT: S T AODRE9+? CITY, ZIPFAX I— CON7ACT Nk�JE S -e � p�V,�� PHOI�� `KU2-6-1d--ao E-?vLAII. STREET a.DDRESS CITY, STATE, — 5 FAX ❑ OWN -MR. ❑ OV,'NiZ-BUIID=R ❑ 0\i'AER AG1:"-T ❑ Co"7"kCTOR ❑ C0.1r1RACTOR AGEI:'T ❑ I.RC MCT ❑ ❑ D'FLOP 't ❑ T -_NAT? CONTRACTORN J,rLICE?�SENU'G- ER LIC�SE TYPE BUS. LIC- CO1JiPANYT'A-1.vmQ n E-N,AIL I F.AX "�5C4 -LCA K �b*er STREETADDRESS CITY, STATE, ZIP PHONE '2- ARCFITECT/EN GN NAME LICENSE XUA/,BER BUS. LIC f COWANY MA %a ,E E-bLkm I FAY, STREET ADDR ESS I CITY, STATE, ZIP I PHONE USE OF ' SFD or DL -PL ❑ J fUI TI-FAh,2LY . PROI-nCT Lel RTII DIJU\D ❑ Y: -:s ?Roj-zCT IN ❑ YES IS i BLDG AN ❑ ti :S BUEDNIG: COho'=. ,CIA✓ URB/ d L\r=-ACE AREA ❑ NO FLOOD ZOME, ❑ No I I EICF=- HOME? ❑ NO DESCP,IPTIOI\T OF 1,'ORiC TOTAL VALUATION M s t k R CtItiD D�4 J V Y r-� } y S By my signature be ow, I ce ttify to each of the following: I am the property owner or authorized agent to act on the property owner's betaJ. I have read this application and the information I have provided is correct. I have read the Description of Work and verify itis accurate. I agree to comply with all applicable local crdnances and state lag's relatir to build' onstnmLlOn. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of A.Pplican /Agent: Date: �. SUPPLEATENTAI Il\TFORvrATIOI�T REQ ULREDva :: ; ::" r =tit=-> ,>= r r. 4 OFFiCFi .... SEOl\L] a'a "��"s OtiEF ThE COLQTERy '$ '� ;�] '3.'Ti S 'YY X• Ck� rr+' �. f ;r.-- t_ uS K.Y.. a'— p AIEPA'f scAPP_2011. doc revised 06121/11 CITY OF CUPERTINO W—M-7 FEE ESTIMATOR — BUILDING DIVISION APPLIANCE EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater J 1PCWHEATR 1 # $29 TOTALS: $29.00 VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, sanitary NeWerUISMCI, 3CII001 District, etc). These fees are based on the preliminary information available and are only an estimate Contact the Dept jor addnl ma L 711113) FEE ITEMS (Fee .Resolution .1.1-053 Ef. ADDRESS: 10566 S De Anza Blvd --7DATE: 11/18/2015 REVIEWED BY: Phuong Plan (.'heck.Fee: APN: 369-38-037.10566 BP#: *VALUATION: 1$1,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair --[PERMIT PRIMARY Commercial Building USE: -T PME Plan Check: PENTAMATION PCWHEAT R TYPE: A WORK Water heater replacement at same location SCOPE L - APPLIANCE EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater J 1PCWHEATR 1 # $29 TOTALS: $29.00 VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, sanitary NeWerUISMCI, 3CII001 District, etc). These fees are based on the preliminary information available and are only an estimate Contact the Dept jor addnl ma L 711113) FEE ITEMS (Fee .Resolution .1.1-053 Ef. FEE QTY/FEE MISC ITEMS Plan (.'heck.Fee: STpp'L N.7 1 -."Ye e PME Plan Check: $0.00 PME Unit Fee: $29.00 PME Permit Fee: $48.00 (.",onslrwfl'Of? Tax: Administrative Fee: JADMIN $45.00 Work Without Permit? 0 Yes (E) No $0.00 Travel Documentation Fee: ITR,4VDOC $48.00 Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 „SUBT0,TA1,S.:.'$171.50 $0.00 'TOTAL FEE: $171,501 Revised: 10/01/2015