12070026 CITY OF CUPERTINO BUILDING PERMIT
BUI LDIN'G ADDRESS: 21530 RAINBOW DR CONTRACLOR:COUNSIL PLUMBING PERM IT NO: 12070026
OWNER'S N'A)IE: ROBLR'IMC LOSKEY 1127 SO.x1ERShf DI? OA IT ISSUFM 07/0V2012
OWNER'S PHONE: 4084998723 SAN JOSE,CA 95132 PHONE NO:1+0x1272-2272
❑ LICENSED CONTRACTOR'S DECLARATION (— F r
/� /�7 BUILDING PERMIT INFO: BLDGELECT PLUMB
License Class ol. Lic.b ( 2119-15719._ r r r
Z mecn RESIDENTIAL a)Nt��tEltclAl,
Contractor (��71Date__7
I hereby affirm that I am licensed under the provisions of Chapter 9� JOB DESCRIPTION: M:I'IACB SI:WI:R 1.INIS AND ADD PROI'I'R-I'1'CI.I"AN Otf"I"
(commencing,,ith Section 7000)of Division 3 of the Business& Professions
Code and that my license is in full force and effect.
hereby affirm under penally of perjury one of the following two declarations:
I h;we 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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor-Arca: Valuation:53900
Section 3700 of the Labor Code,Ior the perfornanee of the work for which this
permit is issued, APN Number:36638021.00 Occup:uwv'1).pe:
,%1'1'1.1(:AN'"I'CER7'IFICA'FION
I certify that I have read this application and stale that the above information is
correct IagreetocomplyWithallCityandcountyordinancesandstatelawsrelating PERMIT' EXPIRES IF WORK IS NOI STAR'1'1sD
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned propcny for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, r . ) r
costs,and expenses which may accrue against said City in consequence oflhe 180 DAYS FROM LAST CALLED INSPECTION.
ION.
grunting of this permit. Additionally,the applicant understands and will comply �7
with all non- in source regulations per the Cupertino Municipal Code Section Issued by-� i� Date: /,
9.18. r
Sign alurc. y Datc
RF.-ROOFS:
❑
OWNER-BUILDER DECLARATION All roofs shall be inspected prior toany routing material being installed. It roof is
installed without first obtaining an inspection,I agree to remove all new materials lin
hereby affirm that I am exempt from the Contractor's License Law formic of inspection
the following two reasons:
I.as owner of the propcny,or my employees with wages m their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended cr offered for sale(Sec.7044,
Business&Professions Code)
I,as owner ol'the property,
,not exclusively contracting with licensed contractors to ALL ROOF COVERINGS'10 BE CLASS"A"Olt HE]'I
construct the project(See.7044.Business&Professions Code).
I hereby affirm under penally of perjury ane of the following three IIAZARDOUS NIA'I"F.RIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 695 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California IIcalth&Safety Code,Sections 2,505.2,,33.and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter r 9.12 and the I Ic:lllll S.
performance ol'the work for which this permit is issued. Safely Code.Section 25532(a)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I arse equipment nr devices whicli emir hazai daus air
Section 3700 of the Labor Code,for the performance of the work Ior which this contaminants as defined by the Bat.Area Air Oddity Manag menu District 1 wi11
permit is issued maintain compliance with the Cupertino Municipal Code.Chaplet 9,12;End the
Health&Safely Code.Sections�Zale:
55055533,and 25534.
1 certify Ilial in the performance of the work lot which this permit is issued.I shall mq
not employ any person in any manner so as to become subject to die Worker's O r 1 lhorizrd a n :
Compensation laws of California. II',after making this certificate ofcxemption,I I
become subject to the Worker's Compensation provisions of the Labor Code,I must AV
Ionhwith comply with such provisions or this permit shall be deemed revoked CONSTRUC] LENDING AGENCY
I hereby affirm that there is a construction lending agency for the pariormance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I cenify that I have read this application and state that the above information is Lender's Name
correct I agree to comply with all city and county ordinances and stale laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnity and keep harmless the City of Cupenino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCIIITF.C'I"S DECLARATION
granting of this permit Additionally,the applicant understands and will comply I understand my phos shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code.Section
9.1& Licensed Professional
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 21530 rainbow dr. DATE: 07/05/2012 REVIEWED BY: bobs.
APN: 3 U�/ BP#: o (,o 'VALUATION: $3,900
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD Or Duplex PERMITTYPE: 1RPS
WORK sfd replace sewer line and add property clean out.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
TOTALS: $23.00
u„l.. I7,in c'h.rG Plumb. Plan Check I 0.0 hrs $0.00 /a•,. /'I„ t.7n cd
Plumb. Permit Fee: IPPERM/T
uih. h. b p Other Plumb Insp. 0.0 hrs $45.00 Only,P. o Lap.
, "h. /ri,p. hen•: I h,...b Dup. Fla-: /Clrr. /nep. lir:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the relimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (l ee Resolution 11-093 Efl. 7/1/11) FEE QTY/FEE MISC ITEMS
Mutt Chc<k /'cv.
PME Plan Check: $0.00
l'cnnit l'cc:
SIggpl. h'sp l'.r
PME Unit Fee: $23.00
PME Permit Fee: $45.00
(.'nll.rll'ni'ligN �(LP-
Administrative Fee: (ADMIN $42.00
Work Without Permit? 0 Yes 0 No $0.00
,Irh"anrr,l I'lmmint• l'ecs:
Travel Documentation Fee: ITRA VDOC $45.00
Slrone Motion I cc: IBSEISMICR $0.50 Select an Administrative Item
131da Sids Commission Fcc: IBCBSC $1.00
SUBTOTALS: 1 $156.50 $0.00 TOTAL FEE: 1 $156.50
Revised: 07/01/2012
a�'f/ �S'
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 M I /1�
CUPERTINO (408)777-3228• FAX(408)777-3333•buildingCcDcupertino.oro /v—
/c)07Ya(p
tPLUh03Pi1G D MECRAMCAL ❑ELECTRICAL ❑MISCELLANEOUS
PRO=ADDRESS �. )� 2O .APN4 GU.�
OWNER NAME / J PHONE [,//.� �("i;-7 E. INA
STREET ADDRESSD CITY. m;,,Y Q / FAC
CONTACT NAME PHONE EMAIL
STREET ADDRESS CITY.STATE ZD' FAX
❑OwNER ❑ OWNER-BUDDER . ❑ OWNERAGENT XmNTRACTOR ❑CONTRACTOR AGSM ❑ AACHrrE-CT ❑ENGDrEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME /md '^ UCENSENUMBER LICENSE TYP BUS.LCA . SX
COMPANY NAME "101 1 - / E!AII. >.2_D7�O
STREET A
�7ySS TATE,ZIP / �- PHO 72-
ARCHrrELTIENGLNEEt NAME LICENSE NUMBER BUS.LIC p
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑06 wDuP= Cl MULTI-FA ay PROMCf IN wRDI.tN'D ❑ YES PROt Cr IN ❑YES IS THE 9IDG AN ❑ YES
BUDDING: ❑CO� URBAN INTERFACE AREA NO FLOOD ZONE (I NO EICIfl_R HOME: 0 N
DESCRIPTION OF WOR:C
la4P from c �c
L,
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 an the property owner's behalf.. l have read this
application and the information I have provided is correct 1 have read the Description of Work and verify it is accurate. I agree,to comply with all applicable local
ordinances and state laws Gelatin d g cCDstructi authorize rep entativm of Cupemnc:c anter the abboo]ve i entifie pmpc.—/.ur inspection purposes.
Signature:of ApplicantlAgrne d�'U L&41 J'd" Dare:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
LJ OVER-THE-COUNTER
❑ EXPRESS
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U
❑ STANDARD
U
❑ LARGE
❑ %1A.loR
i1EP,WircApp_2011.doc revised06/21/11 -