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12010150 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20652 CLEC)AVE CONTRACTOR:TATS INC DBA MR PERMIT NO: 12010150 ROOTER PLUMBING OWNER'S NAME: BURROW BRADLEY J AND JUANITA S 44777 S GRIMMER BLVD STE C DATE ISSUED:01/25/2012 OWNER'S PHONE: 4083661531 FREMONT,CA 94538 PHONE NO:(408)271-2822 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG €ry ELECT _. PLUMB License Class Lic.# t ` MECH RESIDENTIAL Y COMMERCIAL Contractor S ate , I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SEWER REPLACEMENT AND ADD PROPERTY LINE (commencing with Section 7000)of Division 3 of the Business&Professions CLEAN OUT 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 Sq.Ft Floor Area: Valuation:$11070 permit is issued. APPLICANT CERTIFICATION APN Number:36231002.00 Occupancy Type: 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 'a 'S upon the above mentioned property for inspection purposes. (We)agree to save - ` indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF Wt) S T STARTED costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF P T;, SSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM L: ,SLJED INSPECTION. with all non-point source regulatiirts per the Cupertino Municipal Code,Section g' ,'tAL __ Issued by: t, Dat f Signature `="'"' - __....._____Date ❑ OWNER-BUILDER DECLARATION t, ' ^� n RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall In cted[SriQrr to any roofing material being installed.If a roof is the following two reasons: installed witho first bbfaining an inspection,I agree to rernove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applirtnt: Date: 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 declarations: HAZARDOUS RIATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,2.5533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to becorne subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 Owuer or, tlrtzItC /` 1� /� forthwith comply with such provisions or this permit shall be deemed revoked. Date: / ct CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance ofva rk's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnity and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. Sir;nature Date Licensed Professional 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: PERMIT# OWNER'S NAME: PHONE# D 3/ GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: `"� - 45_ Signature Date Please check applicable subcontractors and complete the following information: 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 Tile Owner/Contractor Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # Sec: Tv7p: Rng: Sub: Blk: Lot: APN . . . . . . . . 36231002 . 00 DATE ISSUED. . . . . . . : 01/25/2012 RECEIPT #. . . . . . . . . : BS000015832 REFERENCE ID # . . . 12010150 SITE ADDRESS . . . . . 20652 CLEO AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BURROW BRADLEY J AND JUANITA S ADDRESS . . . . . . . . . . : 20652 CLEO AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : GUSTAVO SOTO 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 A14OUITT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1.00 41. 00 0. 00 41.00 0 . 00 1BCBSC VALUATION 11, 070 .00 1. 00 0 . 00 1 .00 0 .00 1BSEISMICR VALUATION 11, 070 . 00 1. 11 0 .00 1 .11 0 .00 1PPERMITFE FLAT RATE 1 .00 44 .00 0 . 00 44 .00 0. 00 1PRSEWER UNITS 2 .00 44 . 00 0 . 00 44 .00 0. 00 1TRAVDOC FLAT RATE 1.00 44 . 00 0. 00 44 .00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 175 . 11 0 .00 175 .11 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 175 . 11 VISA --------------- TOTAL RECEIPT 175 .11 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ` ADDRESS: 20652 cleo ave. DATE: 01/25/2012 REVIEWED BY: bob s. APN: BP#: VALUATION: 1$11,070 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARYSFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK sewer replacement and add property line clean out. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 2 # $44 TOTALS: $44.00 Plumb.Plan Check 0.01 hrs $0.00 Plumb.Permit Fee: IPPERMIT Ll —t_ Other Plumb Insp. 0.0 hrs $44.00El NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These,lees are based on the relinina information available and are only an estimate. Contact the De t araddn'1 info. FEE ITEMS FEE QTY/FEE MISC ITEMS Ll PME Plan Check: $0.00 El PME Unit Fee: $44.00 PME Permit Fee: $44.00 E I Administrative Fee: ]ADMIN $41.00 Work Without Permit? 0 Yes () No $0.00 Travel Documentation Fee: ITRA FDOC $44.00 sit sf? i 33i `�_t IBSEI&MICR $1.11 Select an Administrative Item Ld<' ;immCorri missi""11eee IBCBSC $1.00 SUBTOTALS: $175.111 $0.00 TOTAL FEE: $175.11 Revised: 1/19/2012 rfit -Z�;n 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(d)cupertino.org MISC PLUMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN# OWNER NAME ko,,Wak�',366 E-MAILa w^ d v✓ - 521 STREET ADDRESSCITY, TATE ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-auaDER `6 AGENT ❑ CONTRACTOR ❑CONTRACTOR AG ENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME t LICENSE NUMBER TLICENSETYPE BUS.LIC#2_t>(4 COMPANY NAME �f U ' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL. FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMELY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK !e ! y / !vt fiI oc TOTAL VALUATION: / O RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct.j 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 builds vonstructio-a I_ au ct�resentativzs of Cupertino to enter the above-identified property for inspection pu(poses. Signature of Applicant/Agent: Date: / ✓ �d PLEMENTAL INFORMATION REQI.I D o JCE USE ONLY OVER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD U < ❑ LARGE a ❑ MAJOR MEPMfscApp_2011.doc revised 06/21/11