12090173f
CITY OF CUPERTINO BUILDING PERMIT
BIIILDINGADDRESS: 1138KENTWOODAVE CONTRAC'I'OR:MIKE000NSILPLUMBING PERMITN0: 12090173
INC
OWNER'S NAME: SHANNON RAYMOND M AND BARBARA 1915 O'TOOLF,WAY DA'Z'E ISSUED:09/19/2012
OWNF,R'SPBONE: 4089968402 SANJOSE,CA 95131 PIIONENO:(408)272-4900
❑ LICENSED COQ IRAC`f0R'S7 DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class l —36 -7
Lie.# 6 90ce1
/�. I- i\11ECId r RESIDENTIAL r DI
COM ERCIAL (-
Conlmclmr A"r-e ate f
k JOB DESCRI PTION: INSTALL NEW SEWER LINE AND PROPERTY LINE CLEAN
hereby affirm that I am licensed under the provisions of Chapter 9 OUT
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that nry license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a cerli Gcate 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.FI Floor Area: �'a_luvNnn_:,$7877
Section 3700 of the Labor Code,for the performance of the work for which this 16
permit is issued.
ANN Number:35931054.00 Occupnncy'1'3pe:
A I'I'LIC.\N'I'CFR'I'1 FIG\'PION
1 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 10 enter PERMIT E?CPIREi �I'F, VQRK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save '? '>p
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN ISO 1 AYS O' FS ERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
180 DAYS , O �LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source re ulations per the Cupertino Municipal Code,Section
9.18. Issued by
��— Dale:
Signature 1' ' U Date 9 % �
❑ OWNER-RIIILIIF.R DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 herebyaffirm that I am exempt from the Contractor's License Law fur one of installed without first obtaining an inspection,I agree to remove all new materials for
the following Hyo reasons: inspection.
I,as owner of the property,or my employees with wages is their sole compensation,
will do the work,and the sircture is not intended or oflered for sale(Sec.7044, Signature of Applicant: Dale:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three DA'LARDOUS I\IATERIAI S DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I 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 I Icalth&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided lot by Safety Code.Section 25532(x)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Queliry Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safely Code,Sections 2.5505.2.5533.and 25534.
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,Ir o anthorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I muss Dale d
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS9Rl1171'ION LENDING AGENCY
AI'PI,ICAN'1'CER9'IFIC *rlON I hereby acorn that there is a construction lending agency for the performance of work's
I certify that I have read this application and stale that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state Imus relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCI I ITF.CI"S DECLARATION
gritting of this permit.Additionally,the applicant understands and will comply
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
o ` -
GENERAL PERMIT APPLICATION Irl E I
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 p p I
v\
(408)777-3228 • FAX(408)777-3333• building0euoerino.ora
CUPERTINO '\■/�
IC
PLUMBING ❑MECHA,NICAL ❑ELECRICAL ✓/�j ❑MISCELLANEOUS
PROIECTADDRFSS 3q� j"fen.l J APNF
��lnnon of
OW'NEA NAME n OO I PHONa`*)�C_ c('O) EMAU.
K.r�r•-�o„d
STREET ADDRESS v CrrY, STATE,ZIP FAX
CONTACT NAME PHONE I E-MAR
Sfol� cr czA
STREETADDRESS CITY,STATE, ZIP FAX
❑ OWNER ❑ OWTEI-SUIMEA ❑ OWNERACL T ❑ CONTRACrOR ❑CONTRACTOR AGENT ❑ ARCmOTEa ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �QC LICENSENUMBER LICENSE TYPE BUS.LICtl
\/ CONVANY MI C OUJIO II YlUhtii�.N� FIQ /jC E-MAR �j ` FAX
SIREET ADDRESS 1115 T UJL- I [F1- STATE,ZIP C_� YSe cA /5/371 PHONE
ARCHRECT/ENGINT:EA NAME LICENSE NUMBER x-44 I BUS.LIC N
COMPANY NAME I E-MAB. FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
lr.
USE OF SFD w DUPLEX ❑ MULTI-FAMRY I PROJECT IN W B.OLAND OYES I PROLCT IN ❑ YES I IS TTL BLDG A
❑ N EI YES
SU-DING: CDMMERCLU. URBANMTERFACEAREA NO FLOOD ZONE ❑NO EICHLER.HOMED ❑NO
DESCREMON OF WORKI-Om 1" Ir
�ns+a�li/l /77a,1-I SeL.>Er- li+lE ('oM edq � T7 �//
e-Ie4�Lou
A/ TOTAL VALUA770N: G I RECEIVED BY:
By my signatve below,I certi to each of;he following: I am the property owner or authorized agent m act on the property owner's behalf. I have read this
application and the information I have provided is correct. 1-have read the Description of Work and veriur
ly it is accate. 1 agree to comply wide all applicable local
ordinances and Sate laws relating to Larize uthorepreunativ<s of Cupertino mentor the above-idcmificd p per./for inspection putyoses.
Signature of Apolicant/Agenc Date: /el
PLEMENTAL rNFORMATION REQUIRED OFFICE USE ONLY
y OVER-THE-COUNTER
s
❑
EXPRESS
V
❑ STANDARD
U
Z ❑ LARGE
❑ MAJOR
AgP.WucApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 1138 kentwood ave. DATE: 09/19/2012 REVIEWED BY: bobs.
\ APN: BPH: 'VALUATION: $7,877
*PERMIT Tl'PE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIAIARI SFD or Duplex PENTAi vLTiON IRPSS
USE: I PERIIIIT TI'PE:
WORK install new sewer lihne and property line clean out
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 2 # $46
TOTA LS: 0
blech. /Ian Check Plumb. Plan Check 0.0 hrs $0.00 Dec.. Plan Check
Mech.Permit Fee: Plumb. Permit Fee: IPPERVIT Flee.Permit Fee:
Other,ifech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other E(cr.Insp.
El
,1-Icch.Irty.Fee: Plumb. Lisp. Fee: Flee.lisp. Fee:
NOT& This evimatedoes not include jeer(lite to other Departments(i.e. Planning, Public {Yorks, Fire,Sanitary Seiner District,School
District,etc. . Thesefees are based on the prefindnart information at ilahle and are only an estlnmte. Contact the Dept for aildn'(info.
FEE ITEMS (Fee Resolution 11-053 Eff LL 12 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit 1'ee:
Suppl. Insp Fee
PME Unit Fee: $69.00
PME Permit Fee: $45.00
Construction Tis:
Administrative Fee: ]ADMIN $42.00
Work Without Permit? O Yes Q No $0.00
Arhvnureel Planning Feces:
Travel Documentation Fee: ITRA JtDOC $45.00 A
Strong Motion Fee: IBSEISMICR $0.79 Select an Administrative Item
131dt; Stds Commission Fee: IBCBSC $1.00 -1 C
SUBTOTALS: $202.79 $0.00 TOTAL FEE: $�W 79
Revised: 07(01/2012