12050100I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 21551 REGNART RD I CONTRACTOR ��Mymy I PERMITNO: 12050100 I
OWNER'S NAME:
1 CUPERTINO, CA 950144818 1 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class13 Lic. N 4 'j S Z� 3 (o
Contractor &_Q ,Z—, Date 6 2
1 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.
1 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.
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
permit is issued.
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
to building construction, and hereby authorize representatives of this city to enter
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 consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature___ � Date //V Z
❑ OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
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.
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
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
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.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. 1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RESIDENTIAL t_t COMMERCLAULZr --
KITCHEN REMODEL 240 SQFT,BATHROOM
RELOCATION TO
STORAGE 35 SQFT & BREAKFAST NOOK REMODEL 110
SQ
FT.
Sq. Ft Floor Area: I Valuation: $85000
APN Number: 35622005.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should 1 store or handle hazardous
material. Additionally, should 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: :w//
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature,
Date
I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21551 REGNART RD I CONTRACTOR:
S LARI AMID AND I PERMIT NO: 12050100 REZAIE
NAYE
I OWNER'S NAME:
1 CUPERTINO, CA 95014-4818 1 PHONE NO:
LICENSED CON RACTDRG'S _ECLARATIOIV
License Class Lic. k T[ S 3 3
Contractor _. � {��.1 Z�� Date Z
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
performance of the work for which this permit is issued.
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
permit is issued.
APPLICANT CERTIFICATION
1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. /
Signature
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
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.
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
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, 1
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
forthwith comply with such provisions or this permit shall be deemed revoked.
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
to building construction, and hereby authorize representatives of this city to enter
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 consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
BUILDING PERMIT INFO: BLDG f� ELECT -PLUMB'
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: KITCHEN REMODEL 240 SQFT,BATHROOM RELOCATION
TO
STORAGE 35 SQFT & BREAKFAST NOOK REMODEL 110 SQ
FT.
6/21/12 REVISION NI REMOVE & REPLACE FURNACE, REMOVE AND RELOCATE
WATER HEATER(GARAGE)ETERNAL TANKLESS & INS -FALL NEW GFCI
PROTECTED OUTLET & UPGRADE GAS PIPE TO METER,
Sq. Ft Floor Area: I Valuation: $85000
APN Number: 35622005.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:_��, /�/ /% Date: 4p gllp
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Add
ARCHITECT'S DECLARATION
Signature
Date
I understand my plans shall be used as public records.
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21551 Regnart Road I DATE: 06/21/2012 1 REVIEWED BY: Sean
imam APN: BP#.- _cX-0_>VIV-r-' _ ALUATI_.ON:. [$10,400
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE: ,
WORK Revision #1: Remove and replace furnace. Remove and relocate (garage) water heater eternal -
SCOPE tankless) and install (1) new GFCI protected outlet and upgrade gas pipe to meter.
Mech. Plan Check 0.0 hrs $0.00
Plumb. Plan Check 0.0 1 hrs $0.00
Elee. Plan Check 0.0 Fhrs $0.00
Mech. Permit Fee: IMPERMIT
Plumb. Permit Fee: IPPERMIT
Elec. Permit Fee: 1EPERMIT
Other Mech. Insp. 0.0 hrs $44.00
Other :Plumb Insp. 0.0 hrs $44.00
Other Elec. Insp. 0.0 hrs $44.00
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These tees are hated on the nreliminary information availahle and an, nn1v an estimate_ Contort the Dent fnr addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$130.00
Mechanical
IMFR=<100 Furnace, Forced -Air
Suppl. PC Fee: Q Reg. 0 OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
1 1 #
$26.00
Plumbing
1 IPRWHEATR Water Heater
Permit Fee:
$0.00
Suppl. Insp. Fee,0 Reg. Q OT
0,0
hrs
$0.00
0 # Electrical
$44.00 IBREMRECEP Recep/Switch/Outlets
PME Unit Fee:
$0.00
PME Permit Fee:
$132.00
0 #
$65.00
Plumbing
IPGASRES Piping, Gas <=4 Outlets
Con.�lnwlivn Tdk_.
Administrative Fee: 1ADMIN
$41.00
Q
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
0
�
Travel Documentation Fee: 1TRAVD
$44.00
Strong Motion Fee: IBSEISMICR
$1.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$219.001
$265.00
TOTAL FEE:
$484.00
Revised: 06/30/2012