13010012I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10767 BROOKWELL DR I CONTRACTOR: DRAIN DOCTOR PERMIT NO: 13010012
OWNER'S NAME: HENRY & MAUREEN PAVY 1480 ALDO AVE I DATE ISSUED: 01/02/2013 1
OWNER'S PHONE: 4084469710 1 SANTA CLARA, CA 95054 1 PHONE NO: (408)370 -3082
❑ LICENSED CONTRACTOR'S DECLARATION
License Class T7, L) k Li,. #
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(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 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature r ( — Date ` —72-
❑ OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I 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 of California. If, after making this certificate of exemption, I
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.
APPLICANT CERTIFICATION
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature
Date
JOB DESCRIPTION: RESIDENTIAL
INSTALL NEW PROPERTY LINE CLEANOUT, HANDOUT
PROVIDED
Sq. Ft Floor Area: I Valuation: $4000
APN Number: 36921011.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DA ED INSPECTION.
Issue Date: 112-1
RE- ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: f 4— --- Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
rm--W CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
imADDRESS:
10767 BROOKWELL DR
FDATE: 01/02/2013
REVIEWED BY: MENDEZ
UNITS
APN:
BP #:
*VALUATION: 1$4,000
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
INSTALL NEW PROPERTY LINE CLEANOUT HANDOUT PROVIDED
SCOPE
.Stipp /. 1n�y Fee
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 hrs $0.00
QTY
UNITS
BP FEES
t;lae t'rsrnrit Fe"
Sewer, Sanitary
1PRSEWER
011 "I( C. t:�tec_ Insp. LJ I
1
#
$23
1 e rinit Fee:
.Stipp /. 1n�y Fee
PME Unit Fee:
$23.00
PME Permit Fee:
$45.00
C. "onso-rrction Klx:
—F
Administrative Fee: IADMIN
$42.00
I
I
TOTALS:
Travel Documentation Fee: I TRAVDOC
$23.00
Strony, Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11 -053 UL 711112)
at.-ctr, t'Ian k
Plumb. Plan Check 0.0 hrs $0.00
h lu,:- P/ZI z O'wck
1
Plumb. Permit Fee: IPPERMIT
t;lae t'rsrnrit Fe"
1 icv .lk,c1�. Insp,
Other Plumb Insp. LL hrs $45.00
011 "I( C. t:�tec_ Insp. LJ I
11�'ch. It7 p, Fcc:
A/1111A Inv". hc,,:
I;let Imp.
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11 -053 UL 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fcc:
:Slippl. PC. Fee
PME Plan Check:
$0.00
1 e rinit Fee:
.Stipp /. 1n�y Fee
PME Unit Fee:
$23.00
PME Permit Fee:
$45.00
C. "onso-rrction Klx:
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes (F) No
$0.00
,Idvoncccc /1'lainiin f Fees:
Travel Documentation Fee: I TRAVDOC
$45.00
Strony, Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$156.50
$0.00 TOTAL FEE:
$156.50
Revised: 10/01/2012
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION `v
10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 Q�
(408) 777 -3228 - FAX (408) 777 -3333 - building(a.cuoertino.org d\
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
MEP
M Isc
PRO= ADDRESS � � � ,
AFN $ 369 Z t 01
OWNER NAME
PHO --
E-MAIL
STREET ADDRESS /
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CITY, STATE, ZIP
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FAX
CONTACT NAME
PHONE E -MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARcKITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR N `
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LICENSE ER ` f
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LICENSE TYPE
BUS. LIC #
COMPANY NAME
tic
E -MAIL
FAX
STREET ADDRESS /� /n _ _,
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CITY, STATE, ZIP ` 2tJ.
ONE
ARCHITECT/FTIGINEER(�NAME
LICENSE NUMBER
BUS. UC`#
COMPANY NAME '
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF FD or DUPLEX ❑ MULTI- FAMn.Y
BL=ING: ❑ COMtvIERC1AL
PROJECT IN Wn DLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK i 1
av dic a
TOTAL VALUATION:
RECEIVED BY:�
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 provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the abo7identifiedproperry for inspection puaposes.
Signature ofApplicant/Agent: .x Date: 2_— `2-y 1
SUPPLEMENTAL FNttaTION REQUIRED
OFFICE USE ONLY
a
E'
Y
U
U
OVER- THE - COUNTER
❑ EXPRESS
❑ STANDARD
c
❑ LARGE
❑ MAJOR
MEPMrscApp_2011.doc revised 06121111
I_
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014 -3255
Telephone: 408 - 777 -3228
Fax: 408 - 777 -3333
JOB ADDRESS: ZO 6rVV I<' i-✓tl ✓
PERMIT #
OWNER'S NAME: H a, U,Y�e -.1
AJ
PHONE # 4 o -- I 0
GENERAL CONTRACTOR: t2,C6. % %A oc-' ✓
BUSINESS LICENSE #
ADDRESS: ' Xo ,t, A1) yk
I CITY /ZIPCODE: .1
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
1.— 2 Zr- 13
Date
/ Contractor Signature
t- 2- --2-0)3
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
/ Contractor Signature
t- 2- --2-0)3
Date