12110141 CITY OF CU13ERTINO BUILDING PERMIT
BUILDING ADDRESS: 6351 BOLLINGER RD CONTRACTOR:TATS INC DBA AIR PERMITNO: 12110141
ROOTER PLUMBING
OWNER'S NAME: KOO KWOK K AND MA SIIEUNG T 44777 S GRIMMER BLVD SPI:C DA'Z'E ISSUED: 11272012
OWNER'S PHONE: 4082539679 FREMONT.CA 94538 PHONE NO:(408(271-2822
❑ LICENSED CON' RAC'fO,RI'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License ClassG— 3K/� DateL?— 1 Z.
Lie.q �`� 7 Z
yr�46T _�I— DIECII r RESIDENTIAL r r
Contractor7`/ CODIDIERCIAL
hereby affirm that I am licensed under the provisions Of Cha pier 9 JOB DESCRIPTION: REPAIR FEXIS1'ING SLIVER LINE AND NEW PROPERTY
(commencing with Section 7000)of Division 3 of the Business& Professions LINE
Code and that my license is in full force and effect. CLEAN OUT
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a ceni0cate 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 penin is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by �N
Section 3700 of the Labor Code,for the performance of the work for which this Sq. Ft Floor Area: ,\' Ift n't ga$6000
permit is issued. `� �s
APPLICANT CERTIFICA'T'ION ARN Number:3691900} `:Y Occupancy Type:
I certify[hat I have read this application laid state that the above information is 1tlL _ V
correct.I agree to comply with all city and county ordinances and state laws relating `
to building construction,and hereby authorize representatives of[his city to enterupon �S,
indemnify
above
ndkee harmdsstherty City l'CuertinPurposes.
stl (We)es.jugree 10 eat PERMIT EXURES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against Iiabililies,judgments.
costs,and expenses which may accrue against said City in consequence of lite WIT-11N%1-80 DAYS OF PERMIT ISSUANCE OR
granting of thispemtil. Additionally.the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regular per the Cupertino Municipal Code,Section
9.18.
/ / JJ—2 iz Issued b " Dnte�j 2'f_�
Signature "� Dan.
❑ OWNER-BUILDER DECLARATION ,
RE-ROOFS: .
hereby affirm that I am exempt from the Contractor's License Law for One of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole conirvnsation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business d Professions Code). AL1.ROOT:COVIiRINGS'f0 RF CLASS \"OR BE'1"f ER
hereby affirm under penally of perjury one of the following three
declarations: -
I have and will maintain a Certificate of Consent to self-insure for Worker's IL\'LARDOUS NIATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued California Health&Safety Code.Sections 255115,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Nlunicipal Code,Chapter 9.12 and the Ilealth&
Safety'Code.Section 25532(a).should 1 store Or handle hazardous material.
Section 3700 of the Labor Code,far the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
I cenify that in the performance of the work forwhich this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Coda Sections 25505,25533,and 25.534.
Compensation laws of California. If,aRcr making[his certificate ofexemp[ion.I
become subject to the Worker's Compensation provisions of the Labor Code,I must O"' r a hu '. agent; /!_ 7_7_) Z.
forthwith comply with such provisions or this permit shall be deemed revoked Date:
APPLIC.\\t'CF.R'FI FIC.\TION CONS'TRUCT'ION LENDING AGENCY
I certify that I have read this application and state dial the above information is I hereby affirm than there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize represen[ak es of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities.judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCIII'I*FC`I"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. - 1 understand my plans shall be used as public records.
Signature Date I Licensed Professional
C-k- �, Lt (
'GENERAL PERMIT APPLICATION M E 1
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 950143255 A -
CUPERTINO (408) 777-3228 • FAX(408)777-3333 • buil ri
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PROPrADDRESS /(� 3 5-/ //rel ZF✓ I .FN' �C () 0 /
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awNERNAME Li. / k00 �tI�yFHON= L zs —9G Gy E-M'
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CS1DZsN--TcAfEr NAME
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❑ OWnrDt ❑ OW .BLT>U ❑ OV.NERAGTO`TXC YN, CTOR ❑WWrRACTORAG--7, ❑ ARC-Tr ❑ ]+GTS ❑ ❑ T— T
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AR01,- -?GA'FA Ti&W-- / IJCi- SE NUM3ER 131-1.LIC
CID M3 ANY NAM3' !V I E.MAE. FAX
STRUT ADDRESS I MY,STA E-Zl?
USE OF SFD.DUPLE( ❑ MU1-r;-F FLY PROTcCTN WIDLAND ❑ 13 ?P.OT=N ❑ Y3 iS=ELDc AN ❑ :S
BUTI-DYG: ❑COMMERcIAL t EANN ri-AfACSZAPE. ❑ NO FLDODZ -- ❑NO Oct Y.Ow-- ❑NO
DESCRE'rION OF WORK
n fd G f0 G ra P.(� ✓! C I rn
TOTAL VALUATION: Da� a`� I P3CEIVED BY:
By my signature below,I certify to each of;he following: I am:be prop-:,,owner or a•_tha::zed agent to act on the propc,,+ownc:'s be!:zl,'. I have road this
application and the into m ation I have provided is wrrecL I have read the Description of Wo-k and verity it is acv=te. 1 agree w comply)with all appliczble local
ordin==znd sate laws relating to building consaa n. I an:hor'zn:eprsen¢'yes of Cnperdno to enter the above-idcatided pmnecr`or inspection pui' oses.
Sig:==e of Applieant/AgcnD Date: /l — -7
SU-PPLEN ENTAL-TNTFORFvfATION REQUIRED OFFICE USE '
OtTR-THE-COUNTER
❑ EXPRESS
u
❑ STANDARD
u
❑ LARGE
MAJOR
AC?L4uc4pp_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 6351 bollinger DATE: REVIEWED BY: bobs.
APN: BP#: VALUATION: 1$6,000
*PERMITTYPE: -Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD Or Duplex PENTAMATION 1 RPSS
USE: PERMITTYPE:
WORK repair existing sewer line and new property line clean out.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, building 1PRSEWER �� #
TOTALS: $46.00
Aleck. Plan Check Plumb. Plan Check 0.0 Ills $0.00 Flee. Plan Check
Alech.Permit Fee: Plumb. Permit Fee: IPPERAIIT Free.Permit Fee:
Other Mech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elce.l sp. Ll I
Hech.Aup.Fee: Plumb. hngt.Fee: Elea bup.Fee:
NOTE: This estimate doer not includejees due to other Departments(i.e. Planning, Public H'orks, Fire,Sanitary Sewer District,School
District,etc.). There fees are baser/on the prelintinan information available and are onit,an estimate. Contact Ilse De t or addn'I info.
FEE ITEMS (Fee Rcsohnion 11-053 E2 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee .
PML Plan Check: $0.00
Permit Fee:
Sit/)/)/. Insp Fee
PME Unit Fee: $46.00
PME Permit Fee: $45.00
Consn-uciion Tax:
Administrative Fee: 1ADMIN $42.00
Work Without Permit? O Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA I DOC $45.00
i
Strong Motion Fee: IRSE1SMICR $0.60 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00 15
SUBTOTALS: $179.60 $0.00 TOTAL FEE: .60
Revised: 1 0101/2 01 2