13010109 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10436 COL BY AVECONTRACTOR:GREAT AMERICAN PERMIT NO: 13010109 -
PLUMBING CO INC
OWNER'S NAME: SHOU SHIH POBOX 26942 DATE ISSUED:01/12/2013
OWNER'S PHONE: - SAN JOSE,CA 95159- PHONE NO:(408)279-1515
LICENSEDCONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL - -
l— INSTALL PROPERTY LINE CLEAN OUT
License Class` Lic.#—(Mi n 6i;-
- -
ContractoC heed .dam i. &WtteI'1 ` q3
I hereby affirm than 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. Sq.Ft Floor Area: Valuation:$1950 .
I haveand will maintain Worker's Compensation Insurance,w provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Numb 3l Occupancy permit is issued. P y T)'Pe:
.APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is XPE RES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating 0 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to ent
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA OM LAST CALLED INSPECTION.
indemnify and keep harmless the City.of Cupertino against liabilities,ju Is, _ n -
costs,and expenses which may accrue against said City in consequence /4 �?
granting of this permit. Additionally,the applicant understands and will Issued by: Date: JJ
with all non oint so ulati ' o Municipal Code,Se
9.18.
RE-ROOFS:
Sign . - Date/T22Y� 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.
❑ V OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of _
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER.
I,as owner of the property,or my employees with wages w 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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: - - Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a:Certificate of C6nsent to self-insure for Worker's material. Additionally,should I 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 Management District I
performance of the work for which this permit is issued. will maintain compliance with t e Cape rti cipal Code,Chapter 9.12 and.
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secfi rs 2 505 5 and 53
Section 3700 of the Labor Code,for the performance of the work for whichthis7
permit is.issued. -"
Owner or authorized age Dater
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 CVaconstruction
TION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that therlending 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
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that.the above information is
correct.d 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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
//�BQTli✓o p�
GENERAL PERMIT AP (CATION U M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION U
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 n y M ' w
CUPERTINO (408)777'3228•FAX(408)777-3333•buildino(a. //cuoertino.orD `V'DL ! (v_
LUMBINGMECHANICL ❑ELECTRICAL D NESCELLAN'E`OUS
PROJECTADDRESS Lot-t3!� uge, Ave— A" • ,- ?-, •/ !
OWNER NAME PD SH�`a jn PHONE E-MAIL
STREETADDRESS CCCY,STATE,ZIP FAX
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CONTACT NAME PHONE
E-MAIL
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STREETADDRESS CITY,STATE, ZIP
FAX
❑OwNER ❑ OWNER-BUILDER ❑ OWNERAGENT 14CONTRACrOR ❑CONTRACTORAOENT ❑ ARCHTTECr ❑ENOWEER ❑ DEVELOPER ❑TENANT
CO CTOR NAME LICENSE NUMBERLICENSE TYPE BUS.LIC#
r
COMPANY NAME E-MAIL
FAX
'' y�J,,�,ff/ /.�tt
STREET ADDRESS/ G 17��' N4 A�V - QTY,STATE,ZIP eS PHONE
ARCHU'ECT/ENG (1NEER NAME LICENSENUMBER BUS.LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP
PHONE
USE OF FD or DUPLEX
E3 MULTI-FAMILY PROIECTDIWD.DLAND El YES PROTECTIN YES IS THE BLDG AN YES
BUILDING: COM1D.tERCW. URBAN INTERFACE AREA NO FLOOD ZONE O EICHLERHOMEP NO
DESCRIPTION OF WORK Llv'elmt az 1lv (fzr
TOTALVALUATION: RECEIVED BY:
By my signatu below,I certify toeh 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 he,*provid s k. au
e 'on of Work and verify it is accurate. [agree to comply withal]applicable local
ordinances and smote laws relating to uil ng 'Be representatives of Cupertino to enter the above-identifiedproperty for inspection pui$oses.
Signature of App13Cant/Agent:11� Date:
LEMENTAL INFORMATION REQUIRED OFFICE use ONLY
W OVER-THE-COUNTER
F
Y ❑ EXPRESS ,
m
❑ STANDARD
V
❑ LARGE
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❑ MAAOR
A PMcscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10436 Colby Ave DATE: 01/22/2013 REVIEWED BY: Sean
APN: BP#: "VALUATION: 1$1,950
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition /Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE PERMIT TYPE:
WORK Installation of property line cleanout.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
TOTALS: $23.00
V c h.Hkw tJ=eck Plumb.Plan Check 0.0 hrs $0.00 Er c Mon CAecT- .
:t1ecA. Fermi!Fee: Plumb.Permit Fee: IPPERMIT kSfc+c.f'et;riC t
01her+.firm,Insp. Other Plumb Insp. 0.0 hrs $45.00 01har't:;),.. ,insp, Li I
;L1ech. 7ne/r, f%r<=; Plumb.Insp.Fee: Elm'. b1sp. 'Fee.
NOTE:This estimate does not include fees due to other Departments(te.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prefimiWna information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053!ff. 7111121 FEE QTY/FEE MISC ITEMS
Plun Check I,e:e:
SarppL PC'lee
PME Plan Check: $0.00
Per Haft F'ee:
Suypl. Insp[, :!e
PME Unit Fee: $23.00
PME Permit Fee: $45.00
Consrruction.7irx:
Administrative Fee: IADMN $42.00
Work Without Permit? ® Yes 0 No $0.00
tdra?ac•<�t(i'T�rrsnirarr I=ir<.>.c;
Travel Documentation Fee: ITRA VDOC $45.00
Strong Motion Fee: 1BSEISMCR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
:i 1O 2S $156.50 $0.001-,'`," TOTAL FEEL' $156.50
Revised: 10/01/2012