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12060123 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 931 BLAZINGWOOD AVE CONTRACTOR:GOGO ROOTER PERMIT NO: 12060123 OWNER'S NAME: MURAKAMI SAM S AND HIDEKO 2530 BERRYESSA RD STE 509 DATE ISSUED:06202012 OWNER'S PHONE: 4082534129 SAN JOSE,CA 95132 PHONE NO:(408)282-7026 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL ff License Class t ? 1, Lic.p 9Zy2y INSTALL NEW SEWER LINE AND ADD 2 CLEAN OUTS r (CUPERTINO SANITARY) Contractor tn'27�i,-� Qn�G✓ Date-.�'�� 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 penally 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. Sq.Ft Floor Area: Valualion:$10000 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:36920017.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and slate 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 FROM 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 granting of this permit. Additionally,the applicant understands and will comply Issued by: , Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RF.-ROOFS: SignM�� —� Date MW 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Dale: I hereby affirm that l am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the properly,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) L 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 1 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 I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by The Bay Area Air Quality Management District l performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25.505,25533,and 25534. Section 3700 of the labor Code,for the performance of the work for which this +� Owner or authorized agent: � Dale: permit is issued, I certify that in the performance of the work for which this permit is issued,1 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 CONSTRUMON 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 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 properly for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S ITECT'S DECLARATION costs,and expenses which may accrue 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 FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 981 blazingwood ave. DATE: 06/20/2012 REVIEWED BY: bob s. APN: BP#: 'VALUATION: $10,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK install new sewer line add 2 clean outs. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary IPRSEWER 1 # $22 TOTALS: $22.00 1",1, !4n»('hrcd- Plumb. Plan Check 0.0 hrs $0.00 lL7er.I'/,»a C6rrlr i 1.,:1, l5a mil Iev Plumb. Permit Fee: IPPERMIT F1.1- !',:r,»!r I udrc• 1/r-ch. Imp Other Plumb Insp. 0.0 hrs $44.00 ilrhe,/tzar. ln.p, El .1/erh. Lnu. F�'e: 1'lurnL. LnP. beer F!or. lx,r. hi'r: NOTE: This estimate does not includejees due to other Departments(Le. Planning, Public Works, Fire,Sanitary Sewer District,School District,eta). Thesefees are based on the Prelimina information available and are only an estimate Contact die Dept for addn 7 info, FEE ITEMS (Pce Resolution 11-053 Fll.' 7/1/1/) FEE QTY/FEE MISC ITEMS /'hare r.'hc, k l rr: Sap�pl. /'(1l 2•r PME Plan Check: $0.00 l'rrnrir F,rr: uppl. hop 14,, PME Unit Fee: $22.00 PME Permit Fee: $44.00 ( emso n, lion Ta.c.- Administrative Fee: IADMIN $41.00 Work Without Permit? O Yes (F) No $0.00 ,Kiruna rd 1'laruriu, Fcas: Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee IBSEISMICR $1.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $153.00 $0.00 TOTAL FEE: $153.00 Revised: 06/30/2012 o CITY. OF CUPERTINO 6 ITEMS OF 6 - PERMIT RECEIPT OPERATOR: counter COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36920017.00 DATE ISSUED. . . . . . . : 06/20/2012 RECEIPT # ... . ... ... . ..: ES000017120 REFERENCE ID # . . . : 12060123 SITE ADDRESS. . . . . : 931 BLAZINGWOOD AVE SUBDIVISION . . . . . . : CITY . . . ..... . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . ... . . . . . . . . MURAKAMI SAM S AND HIDEKO ADDRESS . . . . . . . . . . : CITY/STATE/ZIP CUPERTINO CA, 95014-4618 RECEIVED, FROM . . : GOGO ROOTER CONTRACTOR . . . . . . . : DUARTE TADEU LIC # 28801 COMPANY . . ... . .C . . . : GOGO ROOTER ADDRESS .. . . . . . . . . . : 2530 BERRYESSA RD STE 509 CITY/STATE/ZIP . . . : SAN JOSE, CA 95132 TELEPHONE -. . . . . . . . : (408) 282-7026 FEE ID UNIT QUANTITYe AMOUNT PD-TO-DT THIS REC NEW BAL ------ ----------- ---------- ----- -ADMIN HOURS 1 . 00 41. 00 0 .00 41 . 00 0 . 00 1BCBSC VALUATION 10, 000 . 00 1 . 00 '0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 10,000.00 1.00 0 . 00 1 . 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 153 . 00 0 . 00 153 .00 0. 00 METHOD OF PAYMENT. AMOUNT REFERENCE NUMBER - - - ------- - -- ---- - --------------- -------------------- CREDIT CARD - 153 .00 visa ------------- TOTAL RECEIPT 153 .00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- --- ------------------------- -------- ---------------------------- 106 SEWER & .WATER • 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING . GENERAL PERMIT APPLICATION 1 COMMUNITY DEVELOPMENT.DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 � ' CUPERTINO (408)777-3228 • FAX(408)T77-3333•buildina(5,cuoertino.orD /I 22 O PLUb03ING CHAMCALSC ELECTRICAL NUSCELLANEOUS (// Q60�� PROIECC ADD S , ' Ave APN a 0/7 OWNER NAME I PHONE I C I E-MAB. 3TRIETADDRE55 CITY, SLATE,ZB FAX (lP GU Ot' CONTACT N PHONE E-MAB. G STREET ADDRESS // CRY,STATE, DP FAX ❑OwNER ❑ OWNER-BUILDER Clrte OWNER AGENT CONTRACTOR 11 CONTRACTOR AGENT ❑ ARCHTIECT ❑ENGENEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS.IJCp oi COMPANY NAMEV,GG7 E-MAIL. FAX ;7-670P✓ STREET ADDRESSCRY,STATE ZIP PHONE ARCHRER/FNGINEER NAME LICENSE NUMBER BUS.LIC a COMEANY NAME' E-MAIL FAX STREET ADDRESS - CITY,STATE ZIP PHONE USE OF SFu.DU = ❑ MULTI-FAM .Y PROIECriN WBDIAND ❑ YES PROTECT IN ❑YES LS THE BLDG AN ❑ YES BUBDING: ❑WMMFRCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE El No EICHLER HOME. 0 N DESCRIPTION OF WORK T TOTAL VALUATION: oRECEivm BY: ..A By my signature below,I cer-tify to each of the following:. I am the property owner or authorized agent to act on the property !owner's behalf. 1 have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree m comply with all applicable local ordinances and state laws relating m building construction. I authorize rnpmsentatives of Cupertino m enter the above-ideatifiedprope-y for inspection pui�oses. Signature of Applicant/Agent Date: SUPPLEMENTAL INFO TION REQUIRED OFFICE USE ONLY m OVER-THE-COUNTER r_ ❑ EXPRESS Y U ❑ STANDARD U ❑ TARGE 1 � ❑ NWOR MEPMucApp_I011.doc revised 06/2//11 T