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12010072
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 868 S STELLING RD CONTRACTOR:TATS INC DBA MR PERMIT NO: 12010072 ROOTER PLUMBING OWNER'S NAME: BLAIS ROBERT A AND NAOMI S 44777 S GRIMMER BLVD STE C DATE ISSUED:01/10/2012 OWNER'S PHONE: 4089126101 FREMONT,CA 94538 PHONE NO:(408)271-2822 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class —3 Lic.# MECH r- RESIDENTIAL� COMMERCIAL Contractor (A VVI t'A" Date of l I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SEWER REPLACEMENT AND CLEAN OUT (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 Sq.Ft Floor Area: Valuation:$6000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35922009.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and to that the above information is correct.1 agree to comply with al city and ou ty ordinances and state laws relating to building construction,and h by al ize epresentatives of this city to enter PERMIT EXPIRES IF WORK IS NOT ST TED upon the above mentioned pr erty for' spec ion purposes. (We)agree to save indemnify and keep harmle the City f Cu rtino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT IS N EOR costs,and expenses whic ay accru agai t said City in consequence of the 180 DAYS FROM LAST CAL D rD1S ION. granting of this permit. A itionally the plic n tands and will comply �y with all non-point so ce r ul e C Mum i al Code,Section { P g P 9.18. Issued b r t Signature Datell r' ❑ OWNER-BUILDER DECLARATION rya nam RE-ROOFS: All roofs shall be inspectii prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without)i�aining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safetyde,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cup ti Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Sectio 5je ( should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,sh I uipment or devices which emit hazardous air contaminants fi the Bay Area Air Quality Management District I will permit is issued. maintain co pli nee he CupertinoMunicipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health& fe Co e, 533,and 25534. 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 O or aut 1 !l become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 1 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35922009. 00 DATE ISSUED. . . . . . . : 01/10/2012 RECEIPT #. . . . . . . . . : BS000015720 REFERENCE ID # . . . 12010072 SITE ADDRESS . . . . . : 868 S STELLING RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : BLAIS ROBERT A AND NAOMI S ADDRESS . . . . . . . . . . : P 0 BOX 1386 CITY/STATE/ZIP . . . : CUPERTINO, CA 95015-1386 RECEIVED FROM . . . . : ADAM COLON CONTRACTOR . . . . . . . : TATS INC LIC # 23496 COMPANY . . . . . . . . . . : TATS INC DBA MR ROOTER PLUMBIN ADDRESS . . . . . . . . . . : 44777 S GRIMMER BLVD STE C CITY/STATE/ZIP . . . : FREMONT, CA 94538 TELEPHONE . . . . . . . . : (408) 271-2822 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 .00 41.00 0 . 00 41.00 0. 00 1BCBSC VALUATION 6, 000 .00 1.00 0 . 00 1.00 0. 00 1BSEISMICR VALUATION 6, 000 .00 0.60 0. 00 0 .60 0. 00 1PPERMITFE FLAT RATE 1 .00 44.00 0. 00 44 .00 0. 00 1PRSEWER UNITS 1 .00 22.00 0. 00 22 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 44.00 0. 00 44 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 152.60 0. 00 152 .60 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 152 .60 VISA --------------- TOTAL RECEIPT 152 .60 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 4b"76 - O PERMIT# d OWNER'S NAME: no,O of 3 5 PHONE# qv-6 o ` 3 3 GENERAL CONTRACTOR: (p eo-Tjc,,r BUSINESS LICENSE# ADDRESS: 1 I I IS - M QV/ CITY/ZIPCODE: *Our municipal code requires all businesses working in the city ave a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCU NCY the C IONS) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL S O S HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. t J I am not using any subcontractors: l 1 Signature 6ate Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Z�Z/ Tile i wrier/Contr for Signature D e CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 868 s. stelling rd. DATE: 01/10/2012 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$6,000 - 1 'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: I I PERMIT TYPE: WORK sewer replacement and clean out. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $22 TOTALS: $22.00 Plumb.Plan Check 0.0 hrs $0.00 _. Plumb.Permit Fee: IPPERMIT Other Plumb 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. . Thesefees are based on the relinina information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (Fee Resolution 11-0531ff 7'1./11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A Stromy Motion Fee: IBSEISMICR $0.60 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 1 SUBTOTALS: $152.601 $0.00 TOTAL FEE: $152.60 Revised: 1/01/2012 1-2 6 c--�) t-� -7 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333• building(a)cupertino.org MISC PROJECT ADDRESS P-T LUMBING ❑MECHANICAL ❑ELECT CAL [:]MISCELLANEOUS OWNERNAME PHONE �� 2 (0 E-MAIL STREET ADDRESS [� $ v�1 IJ.1 Crr.( STATE,ZIP ^ FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGEjr ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGwEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME n(� n LICENSE NUMBER LICENSE TYPE BUS.LIC# - G COMPANY NAME 1k r ©(( / (U I E-MAIL FAX STREETADDRESS( `�J- ` • n Ager 51 crTSTA E PPHONE ARCHrrECTIENG _ R WEENAME LICENSE NUMBER 1 BUS.LIC# 7 C1 COMPANY NAME' E-MAM FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WTI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO PLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the fol 'ng: I am th prop e owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided rrect.,I hav cCior1 of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating buil c on. I a orize r resentatives of Cupertino to enter the above'denn/tti1if d perry for inspection pu#poses. Signature of Applicant/Agent: Date: V UP EMENTAL INF ON REQ=D ,,/OFFICE USE ONLY L7 OVER-THE-COUNTER ❑ EXPRESS Y U S ❑ STANDARD U ❑ LARGE 4 ❑ MAJOR MHPMIscApp 201 Ldoc revised 06121111