12050155 CITY OF'CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10392MENHARTLN CONTRACTOR:ABB=QBE PERMIT NO: 12050155
DE+EftMfNED
OWNER'SNAhIE: ERICSCIIAFER A(Z 'S DATE ISSUED:0521/2012
OWNER'S PHONE: 4082572228 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOBDESCRIPTION: RESIDENTIAL COMMERCIAL
License Class 3 Lic.l ' Q Z� -�S— — PROPERTY LINE CLEAN OUT
SEE NOTES*
Contractor ` Date
1 hereby affirm 11 at 1 am licensed under the provisions or 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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$3500
1 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:37516008.00 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 R M 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 (- 24 � a
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: N
with all non-point sourculations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signator -- — DateAll roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
'inspection.
❑ OWNER-RUILDER DECLARATION
I hereby affirm that 1 em exempt from the Contractor's License Lew for one of Signature of ApplicmC Dale:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my errployces 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. 1 will
I hereby affirm under penally 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 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use a fpmenl or devices which emil hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Be ea Air Quality Management District I
performance of the work for whichthis permit is issued. will maintain compliance wi1M1 the C ino M1lunicipel Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safely Code,Secti ,25533,end 25531.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Dale:
permit is issued. L
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of Cal ifomha. 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. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that 1 have read this application and stale that to 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, ARCHITECT'S DECLARATION
costs,and expenses which may acerae 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
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37516008. 00
DATE ISSUED. . . . . . . : 05/21/2012
RECEIPT #. . . . . . . . . : BS000016868
REFERENCE ID # . . . : 12050155
SITE ADDRESS . . . . . : 10392 MENHART IN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ERIC SCHAFER
ADDRESS . . . . . . . . . . : 10392 MENHART IN
CITY/STATE/ZIP . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : GARYS ROOTER
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
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 3, 500. 00 1. 00 0. 00 1 . 00 0 . 00
1BSEISMICR VALUATION 3, 500.00 0. 50 0 .00 0 .50 0.00
1BUSLIC FLAT RATE 1 . 00 119. 00 0 .00 119. 00 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 271 .50 0 . 00 271.50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 271. 50 VISA.
---------------
TOTAL RECEIPT 271.50
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: 10392 Menhart Ln. DATE: 05/21/2012 REVIEWED BY: RDW
PUAPN:3-715- I U a8 BP#: 'VALUATION: $3,500
*PERMIT TYPE: PlumbingPermit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
WORK Sewer line replacement with' ro ert ,line cleanout.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary IPRSEWER 1 # $22
TOTALS: $22.00
Plrnt('h.:ck Plumb.Plan Check 0.0 hrs $0.00 facer.. Phnt t.7a rk
birch. !'.unlit Fee: Plumb.Permit Fee: IPPERMIT Fe".
Odmr d/r,h. Insp. Other Plumb Insp. 0.0 hrs L$44.00 Other(ler.Dnp.
Mao h.bz,p. F'c: Phnnh. lisp. Fee: lite,, Insp. Fee:
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 prellmina information available and are only an estimate Contact lite Dept for addn7 info.
FEE ITEMS (Fee Resolution 1I=053 EfT 711//1) FEE QTY/FEE MISC ITEMS
Plan Chuck Pen-.
,Supp/. PC P(w
PME Plan Check: $0.00
Permit Fer:
.Supp/. hivp FlIc
PME Unit Fee: $22.00
PME Permit Fee: $44.00
Construction Tin.
Administrative Fee: ]ADMIN $41.00
Work Without Permit? 0 Yes 0 No $0.00
Adly ncell l'huininw Fees:
Travel Documentation Fee: ITRAVDOC $44.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Ite
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $152.50 $0.00 TOTAL FEE: $152.50
Revised: 04/01/2012
GENERAL PERMIT'APPLICATION LL/J M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION N \J
10300 TORRE AVENUE•CUPERTINO,.CA 95014-3255N Gj I �i
CU PERTINO (408)777-3228•FAX(408)777-3333• building(g�CUDertino.org �O `!®�
PLUMBING MECHANICAL ELECTRICAL MISCELLANEOUS
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❑OWNER ❑ OW-NTR-BtTIIDER ❑ OWNER AGENT ICCOS cToR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINTU ❑ DEVELOPER ❑ TENANT
CO\TRACTOR\ E O ` LICENSE b'UMB --7 ENSE�PE
MPATY TAME O� E-MAIL I FAX y[ V
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STREET A DRESS CITYSTATE,ZIP Q S � I� 1 S (Z. PIIONE
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ARCHITECTIENGI.NEER NAME LICENSE NUMBER BUS.LIC 4
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF LdSFD.,DUPLEX ❑ MULTI-FAMILY PROIEQaWIIDLANO ❑ \'ES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN WTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
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TOTAL VALUATION: 3 S (J RECEIVED UY: CAJ
By my signature below,I cenify to jeacF-cl,
I prope net or authorized agent to act on the property owner's behalf. 1havereadthis
application and the information . have r Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating ton. orize r presentatives of Cupertino to enter the above-i enti ed property for inspection pUiposes.
Signature of ApplicandAgem: Date: 57?u �--
PL MENTA1,DIFORMATION REQUIRED OFFICE USE ONLY
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❑ EXPRESS
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❑ STANDARD
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A1ERWiscApp_201 L.doc revised 06121111