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12010168CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18780 TILSON AVE CONTRACTOR: SPEEDY ROOTER PLUMBING OWNER'S NAME: SHEN(_)Y A.IAY W AND PATEL UR3A 137 BELLEVUE AVE OWNER'S PHONE: 4083483689 SAN JOSE, CA 95110 ❑ LICENSED C NTRACTOR'S DECLARATION C License ClaAthat Lic. # Contractor I hereby afm 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: [ 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 shite 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 indenrrrify and ke armless the City of Cupertino against liabilities, judgments, costs. and ex ses hidr ma accrue against said City in consequence of the granting of is pc tit. Ad iorrally, the applicant understands and will comply with all r)fin- of source r g aticxi er the Cupertino Municipal;;71' mate. / ❑ OWNE -BUI :DER I)FC_'LAR4T[ON ' I h eby affirm that I a ee rpt 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 (tie structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, an, exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I 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 (tie Labor Code, for the performance of the work for which this permit is issued. I certify that in tire performance of the work for which this permit is issued, I shall not ernploy 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 in' forthwith comply with such provisions or this permit shall be deemed revoked. PERMIT NO: 12010168 DATE ISSUED: 01/30/2012 PHONE NO: (408)234-8134 a� BUILDING PERMIT INFO: BLDG F_ ELECT PLUMB MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: REPLACE SEWER LINE LATERAL FROM HOUSE TO STREET, ADD PROPERTY LINE CLEAN OUT \A4 J� Sq. Ft Floor Area: n: $3800 APPLICANT CERTIFICATION I certify that I have read this application and state that the above in is V correct. I agree to comply with all city and county ordiriances 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 (hits permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date APN Number: 37517036.0 _r',' '# Occupancy Type: PERMIT IE FIRES IF WORK IS NOT STARTED WITHIN.4$0 DAYS OF PERMIT ISSUANCE OR 180 D YS FRO AST CALLED INSPECTION. Issued by: O 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 reprove 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 & Safetv 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 I will rear ar coillpjiance with re Cupertino Municipal Code, Chapter 9.12 and the. alt( & Say Code, . .ctionsa5505, 25533, and 25534. Date: I hereby affirm tha4 re is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Nanre Lender's ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION � VRO ADDRESS: 18780 tilson DATE: 01/30/2012 REVIEWED BY: tarry s APN: BP#: VALUATION: 1$3,800-� PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY PENTAMATION 1 RPSS I!SE: SFD or Duplex PERMIT TYPE: WORK replace sewer lateral from house to street. add property line clean out SCOPE APPLIANCE / EQUIP TYPE FEE ID ... FEE QTY UNITS BP FEES Plumb. Permit Fee: IPPERMIT Sewer, Sanitary 1 PRSEWER 1 # $22 PME Plan. Check: $0.00 F71 PME Unit Fee: $22.00 PME Permit Fee: $44.00 F-1 TOTALS: $41.00 Werk Without Permit? 0 Yes (j) No $22.00 NOTE: This esk'lnNtte dues not tltcluaeDees nue l0 diner Lepur[nsenew je.c. a eurarrsagr ....... ... • - -• _ _.- _- _ _. tnstrict, erc:/. mese ees the uuwu ure gree rcesrrareur FEE ITEMS '' : y :.s a, ,r 11 i ;_> _ ' . 7 1,'I I ... FEE Plumb. Plan Check 0.0 hrs $0.00 MISC ITEMS Plumb. Permit Fee: IPPERMIT Other Plumb Insp. 7fL!1 PME Plan. Check: $0.00 NOTE: This esk'lnNtte dues not tltcluaeDees nue l0 diner Lepur[nsenew je.c. a eurarrsagr ....... ... • - -• _ _.- _- _ _. tnstrict, erc:/. mese ees the uuwu ure gree rcesrrareur FEE ITEMS '' : y :.s a, ,r 11 i ;_> _ ' . 7 1,'I I ... FEE QTY/FEE MISC ITEMS PME Plan. Check: $0.00 F71 PME Unit Fee: $22.00 PME Permit Fee: $44.00 F-1 Administrative Fee: ]ADMIN $41.00 Werk Without Permit? 0 Yes (j) No $0.00 Travel Documentation Fee: ITRA UDOC $44.00 IBSEISM1CR $0.50 Select an Administrative Item _B1 Con -if c=r 1 ::Mm IBCBSC $1.00 SUBTOTALS: $152.50 $0.00 TOTAL FEE: $152.50 Revised: MU/2U12 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 37517036.00 DATE ISSUED.......: 01/30,/2012 RECEIPT #......... BS000015864 REFERENCE ID # ... 12010168 SITE ADDRESS .....: 18780 TILSON AVE SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER SHENOY AJAY W AND PATEL URJA ADDRESS 18780 TILSON AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM RICHARD S ALVAREZ CONTRACTOR SPEEDY ROOTER PLUMBING LIC # 23086 COMPANY ..........: SPEEDY ROOTER PLUMBING ADDRESS 137 BELLEVUE AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95110 TELEPHONE (408)234-8134 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- ---------- 1ADMIN ------------- HOURS ---------- 1.00 ---------- 41.00 ---------- 0.00 41.00 0.00 1BCBSC VALUATION 3,800.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 3,800.00 0.50 0.00 0.50 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 1TR.AVDOC FLAT RATE 1.00 44.00 0.00 ---------- 44.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 152.50 0.00 152.50 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 152.50 --------------- 152.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER,/LATERAL J o(�-,g PERMIT APPLICATION GENERAL P MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING D ISIONcV� 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255[a MISC (408) 777-3228 • FAX (408) 777-3333 • building(&guprti eno.org CUPERTINO PLUMBING MECHANICAL ❑ELECTRICAL%� ❑MISCELLANEOUS( /� / % C/ C �l / 2-1 APN $ /-7�' -I ^ FRS S! /� PHONE Ve 9 2 /� J�Q M� _114 �Y m STATE, ZIP/� STREET ADDRESS - j C �� x GlJi�/ FAX CONTACT NAME %J �v r /�% PHONE C1TYi 1 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT �NTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGWEER ❑ DEVELOPER ❑r TENANT CONTRACTOR NAME /�/j /n} /��// LICENSE �7 S LICENSE TYPE/` �/ BUS. LIC # "� ;3, L l! �T I/ I E-MAIL COMPANY NAME � %% /I� FAX (� , CITY, STATE ZIP/i�C PHONE LICENSE NUMBER ARCHITECT/ENGINEERME BUS. LIC # E W ESTZEETADDRESS FAX CITY, STATE, ZIP PHONE II USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WALAND ❑ YES PROTECT IN YES URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES MCHLHR HOME? ❑ NO BUILDING: ❑ COMMERCIAL DESCRIPTION OF WORK oll TOTAL VALUATION: 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 have the Description of Work and verify it is accurate. I agree to comply with all applicable local application and the information I have provided is correct -j read ordinances and state laws relating to building constructionb I authorize representatives of Cupertino to enter the above -identified property for inspection pu{poses. Date: Signature of Applicant/Agent: SUppLEME11TAL, INFORMATION REQLMED OFFICE USE ONLY ❑ OVER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD U < LARGE LOI MAJOR MEPMucApp_2011.doc revised 06121111