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12120046 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11650 WILDFLOWER CT CONTRACTOR:LECLAIRE RANDY R AND PERMIT NO: 12120046 DEBRA OWNER'S NAME: LECLAIRE RANDY R AND DEBRA 11650 WILDFLOWER CT DATE ISSUED: 12/10/2012 OWNER'S PHONE: 4084067763 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION gUILDING PERMIT INFO: BLDG� ELECT� PLUMB� License Class Lic.# � � � MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby aftirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SEWER REPLACEMENT (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following rivo declarations: t 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• Valu �on:$250 [have and will maintain Worker's Compensa[ion Insurance,as provided for by � .� Section 3700 of the Labor Code,for the performance of ihe work for which this permit is issued. APN Number:36619057.00 ' cupa Type: APPLICANT CERTIFICATION �`� 4�`� 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 pERMIT EXPIRES IF V� � RK IS NOT STARTED to building construction,and hereby authorize represen[atives of this city to enter • t upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DA�'�Q�=- RMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, ig� DA RO �:A�T CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the : granting of this permit. Additionally,the applicant understands and will comply ��'"` I��fir r 1�� with alI non-point source regulations per the Cupertino Municipal Code,Section Issued by• � Date: U 9.18. °,,,,r . Signature Date '�A�,� �� RE-ROOFS: OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material beng installed.If a roof is installed withoi8 first obtaining an inspection,I agree to remove all new materials for I hereby aftirm that I am exempt from the ConMactor's License Law for one of �nspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contrac[ing with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby aftirm under penalty of perjury one ot'the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the [have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. 1 have and will maintain Worker's Compensation Insurance,as provided for by 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 �ontaminants as deTined by the Bay Area Air Quality Management District I will ermit is issued. maintain compl' ce �th the Cupertino Municipal Code,Chapter 9.12 and the P Health&S ty e ctions 25505,25533,and 25534. [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 pW �zed agent: -- y� Compensation laws of Califomia. If,after making this certificate of exemption,I Date: �/ become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of Hork's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, , costs,and expenses which may accrue against s ' City in consequence of the ARCHITECT S DECLARATION granting of this permit.Additi ,the app' t nderstands and will comply I understand my plans shall be used as public records. with all non-point source atirns pe ino Municipal Code,Section 9.18. i� �• Licensed Professional Signature % Date � � G� �� ,j , _ � � --�� J�' � � GE[�tEF2AL PERMiT APPLICATtON � P � COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION , 10300 TORRE AVENUE•CUPERTINO, CA 95D143255 ��'�� CUPEftTINO ��8�777"3228• FAX(408)777-3333� buildina(a�cu�eriino.orq LLTMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLAI�EOUS �.�/ PROIECT ADDRESS j� � l ,� ��1'iJ� C�-- - I °.PN R L� t--f,� � � �-1 _.. �`�` _�r� l.t, � OW7�r.'R NAME , �" PAONL E-Mf.II. ` ftfi-+2s �R,� � ��v STREETADDRESS �. /,��/ .{-1 1..� CRY� //� sC/ J ' / ( FAX c.�, L/� /� ` CONTACT NAME 1 � ` PHONE E-MAR, � STtZ:.e""CADDRESS C1TY,SCATE, ZIP F.4X �pWN=Jt ❑ 0�'N'it-flL'P�ER ❑ OVINIItAGE1dT ❑ CONTR4ROR ❑CDN7R1,Cf0RAGrT'T. ❑ ARCI-7TcCT ❑r'a1G�N'��t ❑ DEVELOP�t ❑ 7r'T.Iq1.�!' GONTRACTOR t�'AME I LICENSE NUMBER L1CCcTTSE TY?E BUS.LIC� �� COMPANY TAN�E E-MAIL ' FAX STR.Ee'T ADDRESS • CI7Y,STA�,ZIP PHONE AR�i11'ECT/ENG7NEcR 11At.�� LICENSE NLIMBER I 3US.L1C� CO MP!.NY NAME' E-MAIL FAX STR_EET ADDRESS CI'IY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MTJLTI-FA.T.�_Y PROI'cCf IN WII.DLAND ❑ 1'-rS I PROJEC7IN ❑Y-rS IS 7'Ff BLDG AN ❑ Y=S BUILDAIG: �COMMERCIAL URBAN A''�r1tFACE AREA � NO FLOOD ZONE ❑NO DC7�..IIt HOME7 ❑NO DESCRIPTI0110F WORK C� :4-�L-T � � � � — ls'. �� /?� TOTAI.VALUA770N: I RECEIVED BY: By my signature btlow,I certify to ezch of the follo ' asn th e o�;�ner or euthorized agent to act on the prope;ry oc.�ner's behzlf. I have:ead this application uzd`1,e inio�nation I bzve pro��ded' orrect I h - D�cription of Work and veri."y it is accurzte. I aorce to comply��th al]applic-�']e locz] ordir.a�ces and sate laws relzting to buildir ons ctio resentarives of Cupetriao to enter che above den �edprope,:�;or inspection pus�eses. 5ienztwe ofApplicznUP.geat: �j Date: IL� �� S • L INFORtvi�.TION REQLTIRED OFFICE USE ONLY � ❑ OYEIi-THE-COUNTER Y �' ❑ E�I'RESS U � ❑ STANDARD U � ❑ L4FGE ❑ ht:4JOR M'c'P?�1'ua4pp_1011.doc revised 06/?I/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 11650 Wildflower Ct. DATE: 12/10/2012 REVIEWED BY: jsg APN: BP#: `VALUATION: $250 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS. USE: PERMIT TYPE: woltK Sewer re lacement SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $23 TOTALS: $23.00 tt��<.ir. Pt�zn t'Yi<:�;; Plumb.Plan Check 0.0 hrs $0.00 E:r��_ t�'<,�.C`h�r.l{ j-t��c�!_ f'errrut f'�c� Plumb.Pernlit Fee: IPPERMIT Z;Irc F'err�:ir I��E� t)Ylrer:l fec�h. Ireri�. �thel'P�ulTlb I11Sp. 0.0 hTS $4rJ.�� (1thc�F�/�Ie�.Ittsp. 1�1ac�1�.1a1��. /°��e: T'hr,ulz (1;.>Jz F;v��: /;isc�_Ir�sE�. !'��e� NOTE:This estimate does not inelude fees due to other Departments(i.e.Planning,Publie Works,Fire,Sanitary Sewer Distriet,School District,etc . These ees are based on the relimina in ormation available and are onl an estimate. Contact the De t or addn'1 in o. FEE ITEMS jFee Resolution 11-053 E f' 7%L'12) FEE QTY/FEE MISC ITEMS /�lC]YI t.{7t.'<'�i /'�c't': :�7t�T�1l. 17(,��`c`E' PME Plan Check: $0.00 1'et•�nit f��cr: :Saa��a�l. Irrc1�1�'c°t� PME Unit Fee: $23.00 PME Permit Fee: $45.00 ('r�fzstr•uczrorr 1 o:r: Administrative Fee: IADMIN $42.00 Work Without Permit? � Yes � No $0.00 1cfti�ustcE�clP1<t��n�rht�I��e�s: Travel Documentation Fee: ITn.�vDOC $45.00 � Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: �BCBSC $1.00 ' SUBTOTALS: $156.50 $0.00 TOTAL FEE: $156.50 Revised: 10/01/2012