12090208 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10142 COLBY AVE CON'TRACfOR:SAN JOSE PLUMBING PERMITN0: 12090208
INC
OWNER'S NAME: SUSAN SHIN 19970 MCKEAN RD DATE ISSUED:09252012
OWNER'S PHONE: 4082029334 SAN JOSE,CA 95120 PIIONE NO:(408)296-1820
❑ LICENSED C0NIRAC`f0R'S DECLARATION .1011 DESCRIPTION: RF,SIDEN'TIAL COM\IERCIA1
License Class `-? G Lic.9 rot-TlYG REPLACE MAIN SEWER LINE ABOUT 46" FEE WITH
TRENCH LESS SYSTEM
Contractor 56A -,,bSQ �(iw�1 MS Date O y-25- f Z
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Dhishm 3 of the Business& Professions
Code and that my license is in full force and effect.
1 hereby affirm under penally 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 for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued Sq.Ft Floor Area: Valualion:$4750
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the stork for which this APIN Number:31628031.00 Occupancy Type
permit is issued.
A PP1,1 CANT CE RTI FICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will conn dy Issued b)': Date:
with arl —;,
seµice regulations per the Cupertino Municipal Code,Section
9.18. `/
RE-ROOFS:
SignaDate � `ZS-�Z All roofs shall be inspected prior to any roofing material being installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNF,R-BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License honfor one of Signature of Applicant: Date:
the following two reasons: ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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,
Business 8'Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IIA7,ARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business R Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health S Safey Code.Sections 25505,25533,and 25534. I will
hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and(he
declarations: Health S Safely Coda Section 25532(a)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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 Managenwnt 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 Ilealth S Safely Code,See ' ns'-5 05.'_5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this el o
Permit is issued Owner or authorized age Y- Dale: 09_2x •1
1 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 laws ofCalifornia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
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 performance 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
APPLICANI'CERTIFICATION Lender's Address
I 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 to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, - ARCHITECT'S DECLARATION
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
GENERAL PERMIT APPLICATION �� E
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 I
CUPERTINO (408)777-3228 • FAX(408)777-3333• building0cuoertino.oro \n ,U
sc
PLUMBING ❑MECHP.MCAL ❑ELECTRICAL ❑MISCELLANEOUS
PROTECT ADDRES 1. �- I APPpN# I 2a 0Co Le 3 I
OWNER NAME SS-(S IJ &1+I PHONE L{`�O� l E-MAIL
UAP-IN6-itr V>A on2 2- 33
STREET ADDRESS CITY, STATE,zzIIyy FAX
2/ C /fie a-N•c- CU. ,rz- 1•kV0
CONTACT NAME I PHONE E-MAIL
STREET ADDRESS CI Y,STATE. ZIP FAX
❑OWN It ❑ OWNER-BL-GDER ❑ OWNER AG0.7 2rCONIRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAMI� 111 / u( S U[EN NUMB Sb LICENSE TYPE BUS.LIC A
I' L FAX
COhflANY NAME E-MAIL
0 pA br rI
STREET ADDRESS I CITY,STATE,ZIP PHONE
ARCHITECr/ENGI'EERNAME UCENSENUMBER I BUS.LIC#
COMPANY NAME I E-MAIL FAX
STREET ADDRESS I CITY,STATE ZIP PHONE
USE OF FD m DUPLE( ❑ NfULTi-FAMILY I PROTECT IN WDDLAND ❑ YFS I PROJECT N ❑YES I IS THE BIDG AN ❑ YES
BUILDING: ❑COFAIERCW. r URBANITERFACE AREA NO FLOODZONE NO EICHLER.HOME? NO
DESCRIPTION OF WORK
+ H yevIck- sS 1 SI
TOTAL VALUATION: RECEIVED BY: C�
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf I have read this
application and the information I have mvided i conect. I have read the Description of Work and verify it is ac=te. I agree to comply with all applicable local
ordinances and state laws relating -4 'ng c stn:ction. da jze representatives of Cupertino to enter the above
l-identificd property for inspecrion putposes.
Signature of ApplicandAgen[ �/(..c/– Date: 04`2S —t '2—
b$ L LENTAL INFORMATION REQUIRED OFFICE USE ONLY
v OVER-THE-COUNTER
'>
I' ❑ EXPRESS
Y
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❑ STANDARD
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< ❑ LARGE
❑ MAJOR
1 fEPMucApp_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10142 COLBY AVE DATE: 09/25/2012 REVIEWED BY: SYLVIA
APN: BP#: 'VALUATION: $4,750
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
WORK MAIN SEWER LINE REPLACEMENT
SCOPE
d/ech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Fl,,. Plan Check
hlech. Permit Fee: Plumb. Permit Fee: IPPERMIT Dec.Permit Fee:
Other Mech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other'Flee.Insp.
,IPech.Lisp.Fee: Plumb. Insp. Fee: Flec.Insp. Fee:
NOTE: This estimate floes trot include fees doe to other Departments(i.e. Planning, Public Il'orkc, Fire,Sanitary Server District,School
District, etc. . These feav are based on the prelitninan information availahle ant/are onh,an estinuae. Contact lire De 1 or addn'I in o.
FEE ITEMS (Fee Resolution II-051 Elf 7/I/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = /# Plumbing
Suppl. PC Fee: 0 Reg. Q OT 0.0 hrs $0.00 $23.00 IPRSEI7FR Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. FeeQ Reg. Q OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Conso-uction Tax:
Administrative Fee: I,mAI/,v $42.00 Q
Work Without Permit? Q Yes (D No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITR.f1'DOC $45.00 Building or Structure
i
Strong Motion Fee: /BSFIS,LOCR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $133.501 $23.001 TOTAL FEE: 1 $156.50
Revised: 07/01/2012