12080059CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10872 W ESTATES DR
CONTRACTOR: AMERICAN RESIDENTIAL
PERMIT NO: 12080059
SERVICES OF CA
OWNER'SNAME.: GUYMON SAMUEL. HAND CHARLOTTE
965 RIDGE LAKE RLVU SI'E 201
DATE ISSUED: 081072012
OWNER'S PHONIi: 4082532971
%lE,IPIIIS,TN 38120
PRONE NO: (408) 982-0405
❑1/ LICENSIiDCOK1'RACTOR'SDECLARATION
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PLUMB
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BUILDING PERDIIT LY FO: BLDG ELECT
License Class Lic. 9 /
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COMMERCIAL
Contractor �M-rfzon j)
NIECII RESIDENTIAL
Chap 9
•JOB DESCRIPTION: INSTALL PROPERTY LINE CLEAN OUT-
hereby affirm that I am licensed under the prodsiuns o er
(comnhencing ws'ith Section 7000) of Diyisimh 3 of the Business .4 1'rofessians
'-SUNNYVALE SANITARY
Code and that nn• license is in full force and effect.
I 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 f'or by Section 3700 of (lie Labor Code, for the
performance of the work for which this perms is issued.
Sq Ft boor Area:
Valuation: $5025
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of die work for which this
permit is issued.
AI'N Number. 36922025.00
Occupnncy't\ypr.
APPLICANTCF.RI'1 FICATION
I certify that I have read this application mid slate that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, mid hereby authorize representatives of this city to enter
PERMIT EXPIRES IF WORK IS NOT STARTED
upon file above mentioned property for Inspection purpose's. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAY F OA7 LAST CALLED INSPECTION.
grmuing of his permit Additionally, the applicant understands mid will comply
with'all no - aim source regulatims per the Cupertino Municipal Code, Section
—I ?��
9.18.
_ — - _- Date. -0711
Issue1Z — L / Date:
,Signature-
- -
Ito: ROOFS:
❑ OWNER-EUILDEAt DECLARATION
All roofs shall be inspected prior to any roofing material being installed. If 0 roof is
hereby odfirnh that I am exempt front the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following ima reasons:
inspection.
1, as owner of the property, or my employees with wages ;is their sole compensation.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Signature of Applicant: Date:
Business S Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business S Prolcssions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BE 11rER
Bh\'I'ERIALS DISCLOSURE
hereby affirm trader penalty of perjury one of the following three
declarations:IIA%AI2UOIIS
I have and will maintain a Cenilicate of Consent to self -insure for Worker's
1 have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health S Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health S
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code. Section 25532(x) should I .store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Ray Area Air Quality Management District 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
1 certify that in the perfomlm¢e of die work for which this permit is issued, I shall
Ile th S Safew ode, Sections 25505. 25533, and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, alter making this certificate of exennption, 1
O n t .1 aha .e hge
become subject to the Worker's Compensation provisions of the Labor Code, I musvi
_ — - _ _ _ ' - Date. ._
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS'IRUCI'ION LENDING AGENCY
.\I'1'I-ICAN'I' CER'1'I PIG\TION
1 hereby aim that there is a construction lending agency for the performance of work's
1 certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree t0 comply with all city and county ordinances mid state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon die above mentioned property for inspection purposes. We) agree to save
Lender's Address
indemnify mid keep hamtless the City of Cupertino against liabilities,judgmenls,
costs, and expenses which may aceme against said City in consequence of the
I1'I'ECI"S DECLARATION
granting of this perinit. Additionally, the applicant understands and will comply.\KCI
with all non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
I"I FEE ESTIMATOR—BUILDING DIVISION
jAFADDRFSS:
10872 w Estates dr
DATE: 08/0712012
REVIE)VED BY: Sylvia
UNITS
APN:
13P#:
'VALUATION:
1$5,025
*PERDIIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARYPENTAMATION
USE: SFD or Duplex
$23
ITTYPE: 1RPS6
WORK
Install property line clean out
SCOPE
APPLIANCE / EQUIP TYPE
FEE 11)
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Efec. Permit Fea:
Sewer, Sanitary
1PRSEWER
Other Clec. Insp.
1
#
$23
Pertnit Fee:
Suppl. /asp Fee
PME Unit Fee:
$23.00
PME Permit Fee:
$45.00
Consn•uction Tar:
Administrative Pee: 1ADAON
$42.00
Work Without Permit? O Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRA YDOC
$23.00
Strong Motion Fee: IBSEISh1ICR
NOTE: This eslimote Anes not include fees due to other Departments (i.e. Planning, Public (Yorks, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the Drelintinan• information available and are onh, an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/I/11)
Alech. Plan Check
Plumb. Plan Check 0.0 1 hrs $0.00
El,,.-. Plan Check
Afech. Permit Fee:
Plumb. Permit Fee: )PPERM/T
Efec. Permit Fea:
Other Afech. Insp.
Other Plumb Insp. 0.0 firs $45.00
Other Clec. Insp.
Alech. Imp. Fuc:
Plumb. hasp. Pee:
Mee. lisp. Fee:
NOTE: This eslimote Anes not include fees due to other Departments (i.e. Planning, Public (Yorks, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the Drelintinan• information available and are onh, an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/I/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PCF ee
PMC Plan Check:
$0.00
Pertnit Fee:
Suppl. /asp Fee
PME Unit Fee:
$23.00
PME Permit Fee:
$45.00
Consn•uction Tar:
Administrative Pee: 1ADAON
$42.00
Work Without Permit? O Yes 0 No
$0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA YDOC
$45.00
Strong Motion Fee: IBSEISh1ICR
$0.50
Select an Administrative Item
13lda Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$156.501
$0.00
TOTAL FEE:
$156.50
Revised: 07/01/2012
CUPERTINO
GENERAL PERMIT APPLICATION M E PI^
CONIMUNI TY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95011-3255
(408) 777-3228 • FAX (108) 777-3333 • building(acucerunO:ora
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CONTACT NAME
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❑ OWNER ❑ OWNER -BUDDER ❑ 0W. AGG,
CO CrOR ❑CON CTORAGFM ❑ ARCHITB�, ❑ F GLNiE-.. ❑ DEVELOPER Cl T'_NANT
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ARCHRECTIENGDJEEt NAME
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COMPANYNAME'
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STREET ADDRESS
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USE OF XSM.DUPLEX ❑ MULIJ-FAQ Y PROTECT N WBDLIND ❑ YES
BUILDING: ❑COMMERCLV. URBAN INTERFACE AREA ❑ NO
PROJECT, IN ❑ YES
I FLOOD ZONE ❑ No
IS THE BLDG AN ❑ YES
I EICHLE. HOME. ❑ NO
DESCAIPTTON OF WORX
10 N .E C( A- a O LAT—
TOTAL VAJ.UATION:f00_
RECEIVED BY: vL e
By my signature below, I certify m each of the following: I am ttc prope yy owner or aunccrized agent to act on the pnvpery owner's behal`. I have rad this
application and the information I have provided is 00=CL Ve Tad the Description of Work and verify it is accurate. I agu to comply with all applicable local
ordinances and state laws relating m bui to c nsaucdon. uthoriu repms of Cunerd= :o carer nteab v-identi e3 ompe.—; for inspectionpuPposes.
Signantie of Aopliam/Agene Date:
SUPP i t NF
LATiON REQUAED
OFFICE USE ONLY
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❑ E\PRE55
❑ STANDARD
❑ LARGE
❑ MAJOR
AEPMuc4pp_2011.doc revised 06/21/11