12070194 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19787 LA MAR DR CONTRACTOR:TATS INC DBA MR PERDII'1'NO: 12070194
ROOTER PLUMBING
OWNER'S NAME: MAX AGOSTON 44777 S GRIMMER BLVD STE C DATE ISSUED:07242012
OWNER'S Pl ION'F.: 4082532343 FREMONT,CA 94338 PI LONE NO:(408)271-2822
❑ ! LICENSED CON fRACfOR'S DECLARATION .108 DESCRIPTION: RESIDE\I'IAL COMMERCIALE]
License Class Lie.# REPLACE SEWER LINE
Contractor tyl.%':Qegr34e-,r Date 4' 1'Z
1 hereby nfftrn that 1 am licensed under the provisions of Chapter 9
(emhmencing with Section 7000)of Division 3 of the Business S Professions
Cade and that my license is in full force and effect
I hereby affirm under penally of perjury one of the following Oro declarations:
1 have and will maintain a certificate of consent t0 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. FI Floor-Area: Valuation:$7506
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 ALN Number:36910026.00 Ocrupaney'I'ypa
pemhit is issued.
AI'I'LIC.\N'I'CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORKNISVV'OT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OFTRNN'iKISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter H
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LaCST �AI�LED�NSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which ran)-accrue against said City in consequence of the p 1y 3�' 2G//2�
granting of this permit. Additionally,the applicant understands and will comply Issued by: G1 VA ale: /'V
with all non-point source regulations per the Cupertino Municipal Code,Section fl.�
9.18.
RF-ROOFS:
Signature-' „1� Date—2- `-[•\"Z- [SI7' (s!huahoutTA
•m5 cted prior to my roofing material being installed If a roof is
1 45tst�1 . obtaining an inspection,I agree to remove all new materials for
ills .A
❑ O\\'NI?It-BUILDER DGCLAIi.\'PION
s Signature of Applicant: Date:
hereby affirm that I am ere ipt from the Contractor's License Law for ane of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,md the structure is not intended or offered for sale(Sec.7044,
Business S Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IL\'LARDOUS NIATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safeh'Cada Sections 25505.25533.and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following threemaintihin compliance with the Cupertino Municipal Code,Chu pier 9.12 and the
declarations: Ilealth S Safety Code,Section 25532(a)should I store or handle hazardous
1 have and will maintain a Certificate ofConsent 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
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 S Safely Code.Sections 25505.25533,and 25534.
th
Section 3700 of the labor Code,for e performance of the work for which this Owner or authorized agent:..f/1�/ j2A 0 Date
permit is issued � _ � �
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation Imus ofCalif'ornia. If,alter making this certificate ofesenhption,.I CONS'1'R1JC`fION LENDING AGENCI'
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 performm¢e of
forthwith comply with such provisions or this permit shall be deemed revoked work's for which this permit is issued(Sec.3097,Civ C.)
lender's Name
APP LICANI'CERTI FICAT'ION Lender's Address
1 certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state Imus 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 ,\RCIIITFCI"S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
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 NAP.&U�
FEE ESTIMATOR - BUILDING DIVISION 1�'0'70/9,L
ADDRESS: 19787 la mar DATE: 0712412012 REVIEWED BY: bob s.
\ APN: BP#: 'VALUATION: $7,506
*PERMITTYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration /Addition/ Repair
PRINIARI' PENTANIATION
USE: SFD or Duplex PERMITTYPE: 1RPS
WORK replace sewer line.
SCOPE
APPLIANCE/EQUIP TYPE FEE 11) QTl' UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
ToTA LS: $23.00
,l tech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec.P/an Check
Mech. Permit Fee: Plumb. Permit Fee: I PPERMIT Elec. Permit Fee:
Other,lfreh.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other rice. Insp.
Me&harp.Fee: Phonb. htsp. Fee: Elee.Insp.Fee:
NOTE: This eviinutte does not include Jeer due to other Departments(i.e. Planning, Public /forks, Fire,SanitarySewer District.Schaal
District,etc.). These feLv are based on the rreliminarP information available and are onh,an estimate. Contact the Dept for adtln'I info.
FEE ITEMS (Fce Resolution 11-0. 3 Eff 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit I'ee. .
Suppl. Insp Fee
PME Unit Fee: $23.00
PM8 Permit Pee: $45.00
Concnttction Tax: 17-
Administrative Fee: IAD,b1IN $42.00
Work Without Permit? O Yes (D No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
i
Strong, Motion Fee: IBSE/SMICR $0.75 Select an Administrative Item
Bldg,Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $156.75 $0.00 TOTAL FEE: $156.75
Revised: 07/01/2012
t
GENERAL PERMIT APPLICATION ly M P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 M I
GUPERTINO (408)777_3228 • FAX (408)777-3333 • buildinc(c)cuoertlnc.orD J
Ig PLUMBING ❑MECHANIICAL ❑ELECTRICAL /❑MISCELLANEOUS 40�0'7
PROIECr ADDRESS ► L AFNP -:y
oar
0
OWNER NAME PLO � ' n ^ E-MAIL
STREET ADDRESS L`C[TY, STATE ZIP L _ FAX
� L �
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER A= ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ AR(=CT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACfORN LICIDNS y1. / O Z� LICENSE TYPE I 13115.LICK
COMPANY NAME E-MAIL,/ I FAX
C-0
ST'RgT ADDRESS ,STATE,IIP PHONE
c c e W s3
ARCHTTECT/FNGINEEt NAME LICENSE NUMBER BUS.LIC 0
COMPANY NAME- I E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFO m DWL£I ❑ MULTI-FAMILY PROJECT IN W I O AND ❑ YES PROTECT IN ❑YFS IS itL BLDG AN ❑ YES
BULLDING: ❑COM.IERCIAL URBAN BNTERFACE AREA ❑ NO I FLOOD ZONE 13 No I E1041 tHOME? (3 No
DESCRIPTION OF WORK
TOTAL VALUATION: r ! I RECEIVED BY:
Chi—
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pNperty owner's behalf. 1 have read this
application and the information 1 have provided is W=CL I have read the Description of Work and verity it is accurate. I agree to comply With all applicable local
ordinances and sam laws relating m building construction. I amboritm representatives of Cupertino to enter the above-identified pmpe,:y for inspection purposes.
Signature ofApplicanJAgenu �j �C� a_�o�t/\ Dam:
SUPPLEbEENTAL INFORVU.TION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
— Cl EXPRESS
t
V
❑ STANDARD
U
Z ❑ LARGE
J
❑ MAJOR
MEPMac9pp_1011.doc revised 06/11/11