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12100106 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 10110FIRWOODOR CONTRACI'OR:CONSOLIDATED PERMITNO: 12100106 PLUMBING INC OAVNER'S NAME: SOMERVILLE MARY A TRUSTEE 3732 CUARTFR PARK DR SI'E I) DATE ISSUED: 10/152012 OWNER'S PHONE': 4082551728 SAN JOSE.CA 95136 PHONE NO:(408)978-3093 ❑ LICENSED COV['RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT rj PLUMB F- License Class — G Lic.k5C1�/(�2 r r r NIECII RESIDENTIAL COMMERCIAL Contractor Date S�Z 1 hereby idlarm Char I am licensed tinder the provisions of Cha pier 9 30B 1)F,SCRI PTION: REPLACE SEWER LINE AND INSTALL PROPERTY LINE (conuncncing with Section 7000)of Division 3 of the Business&Professions CLEANOUT Code and that my license is in full force and effect. hereby affirm under penalty of perjury tine 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 lc:-k performance of the work for which this permit is issued. .w 1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.FI Floor Area: Valu 'noir 7 0 Section 3700 of the Labor Code;for the performance of die work for which this Permit is issued, s x� ,\I'N Number:34233034.00 n eu wpe: ,\I'PI,ICANI'CFR'I'IIIG\'fIO,N 6tiS�L� I certify that 1 have read this application and state(hat 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 representatis•cs of this city to enter PERMIT EXPIRES IF N O SNOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save F indemnify and keep harmless the City of Cupertino against liabilities,judgments. WITHIN 180 DAYS n F IT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of(hc 180 DAYS FROM LLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section r 9.18. Issued by: �( Date: i Signatur Date �� ❑ OWNER-RIIILDER DECLARATION RE-ROOFS: NI roofs shall be inspected prior to any roofing material being installed.If a roof is 1 hereby affirm that I am exempt from the Contractor's License Law fur One of installed without first obtaining an inspection,1 agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,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, Signature of Applicant: Date: Business R Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business S Professions Code). ALL ROOF CO\'F;RINGS"1'O BE CLASS"A"OR BETTER hereby affirm under penally of perjury one of the following(here declarations: IIA%ARDOUS MATERIAL S DISCLOSURE I have and will maintain a Ceni ficate 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 Codc,for the California I Ieallh&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 Ilealrh S I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 2.5532(a)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 emir hazardous air contaminants as defined by the Ray Area Air Quality Munagemenr District I will permit i5 issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of date work for which this permit is issued,I shall Health K Safetv Code,Se tions 25505.25533,and 25534. not employ tiny person in tiny manner so as to become subject to the Worker's Compensation laws ofCalifomia. If,after making this certificate of exemption,1 Ow as .e gent: ,��r� become subject to the Worker's Compensation provisions of the Labor Code,I most Date' � "'f-�`_Ci J forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCI'ION LENDING AGENCY ,APPLICAN I'CI•:R'1'IFICAI'10,N I hereby affirm that there is a construction lending agency for the performance of vork's I 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 to conmply with all city and county,ordinances and state laws 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 ,ARCIII'I'IiCI"S DECLARATION of this permit.Additionall)',the applinnt understands and will comply with all non-point source regulatims 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 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10110 Firwood Dr. DATE: 10/15/2012 REVIEWED BY: jsg 2APN: BPN: 'VALUATION: $12,000 *PERMIT TYPE: Plumbing Permit = PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY Multi-Family Dwelling Buildina is PENTAMATION 1RPSS USE: 3 Stories E) Yes 0 No PERMITTYPE: WORK a lace sewer line and instal property line cleanout. SCOPE APPLIANCE/EQUIP TN'PE FEE ID QTl' UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $23 TOTALS: $23.00 N/ech. Han Check Plumb. Plan Check 0.0 1 hrs $0.00 Elec.!'Ian Check Mech. Permit Fee: Plumb. Permit Fee: IPPERMIT 6fec.Permit Fee: Other Mech. /asp. Other Plumb Insp. 0.0 hrs $45.00 Other filed Insp. Mech.Imp. roc: Phrmh. Irr,cp.Fee: @lcc.Insp.Fec: NOTE: This estimate does not includejeer due to other Departments(i.e. Planning, Public If orkst Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelindnan information available and are only an estimate. Contact the De t or atldn'1 info. FEE ITEMS (Fee Resolution 11-053 E1Z 7/1112) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Supp/. Insp Fee PME Unit Fee: $23.00 PME Permit Fee: $45.00 Consnvtction Tar: Administrative Fee: MDMm' $42.00 Work Without Permit? 0 Yes Q No $0.00 Advanced Planting Fees: Travel Documentation Fee: /TRAI DOC $45.00 Strong Motion Fee: IRSEISdnC491 Select an Administrative Item Hide Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $158.52 $0.00 TOTAL FEE: $158.52 Revised: 10/01/2012 C '-) � -- 1ZI06IZ)c.0 GENERAL PERMIT APPLICATION Irl E r COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 w A I A CUPERTfNO (408) 777-3228 • FAX(408)777-3333• building0cuoerino.orD '\9/' v\ ®PLUMBING ❑MECHANIC.A.L [:)ELECTRICAL []MISCELLANEOUS PROIECrADDRESS I APN 2 L., a 3 O3 C... OWNER NAME j PH ✓ E-MAB. STRE'E'T ADDRESS low I CITY, STATE,ZIP�U I FAX CONTACTNAMEI PHO °-MAR l P STREET ADDAES53 7 3 L - - C CRY,STATE. ZIP S F ^'9 ❑ OW - ❑ OWNER-BUILDER ❑ OeRaFJt AGrT'T '�9*01`rn CroR ❑CONTRACTOR AGENT ❑ AR=E ❑E OtNEzR ❑ DevELopm ❑ �' ANT CANFRACTOR NAME / LIC nT'SE NUMBR LICENSE MEL_ I BUS.UCC CDMPMY NAME I E-MAIL - I FAX c4;91bloh, -30 9ig ADDRESS . N I CTY,S T ATE,ZiP PRONE �� ARG=CT/ENGINEER NAME LICENSE NUMBER I BUS.LIC p Y COM ANYNAME' E-MAIL FAX STREET ADDRESS I CITY,STAT; I PHONE USE OF OSM.DUPtE% ❑ M VL FAAGLY I PROrZCr IN WILDLAN0O YES I PROIECr[N ❑YES IS=SLDGAN • ClYESY BLULDBNG: COM -RcIAL LRiSANA'TERFACEAREA NO FLOOD ZONE ❑NO EJCH liomm ❑NO DESCRIPi70N OF WORK Iq n a (/ TOTAL VALUATION: I RECEIVED BY: By my signave below,I ccrti�f m each of the following: I am the pmpery owner or vuthoized agent to act on rhe pmpery owner's behalf. I have r,zd this application and the i0fom:ation lti I ha I is^^ 1 have read the Desciption of Work and verity it it is acv-=e. I ag ,d comply with all applicable local es ordinancand Stam laws ream brit c s:nc I •3orizc representadves of Cuner-,ino to enter the above-identi5ed pmpe:,y for inspection pui�oses. Signature of Applicant/Age ' Dace: SUP? .4L?NFORNLJ\T?ON REQUIRED OFFICE USE ONLY y ❑ OVTR-THE-COUNTER r ❑ EXPRESS ' V ❑ STANDARD V < ❑ LARGE ❑ MAJOR AgPkue9pp_2011.doc reused 06/11/11