12120056CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22406 SALEM AVE
OWNER'S NAME: WEST DENNIS L AND BARBARA J
CONTRACTOR: SAN JOSE PLUMBING INC PERMIT NO: 12120056
19970 MCKEAN RD DATE ISSUED: 12/11/2012
OWNER'S PHONE: 4088887458 1 SAN JOSE, CA 95120 ! PHONE NO: (408)296-1820
❑ LICENSED CONTRACTOR'S DECLARATION
License Class r 6 Lic. # %
Contractor �l�Vl t, �S2l J w��IDfe a — -i 2-
1
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 Date
❑ 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)
1, 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
BUILDING PERMIT INFO: BLDG I— ELECT f— PLUMB r—
MECH RESIDENTIAL f— COMMERCIAL I—
JOB DESCRIPTION: APT 1-3 - PROPERTY LINE CLEAN-OUT
Sq. Ft Floor Area: I Valuation: $2500
APN Number: 32615018.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued
` ROOB.
Al(rofs shal a iiupee}ed p;ror, o a fing material being installed. If a roof is
i °stalled whho firsgbta it inspection, I agree to remove all new materials for
ipect#on. .`
Sit 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 authoriz ag t:
Date: ) --a—
CONSTRUCTION
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building a( ..cuoertino.org
/XLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
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CONTACT NAME
PHONE
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CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER-BUIIAER ❑ OWNER AGENT
❑ CONTRACTOR ❑CONTRACTORAGENT. ❑ ARC=zcT ❑ENGD'-. x ❑ DEVELOPER ❑ T gANr
CONTRACTOR NAME
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LICENSELICENSE
TYPE
BUS. LIC
COMPANY NAME
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CITY, STA i"E
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ARCHITECT/ENG1NEER NAME
LICENSE NUMBER
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COMPANY NAME '
E-MAIL
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF MULTI -FAMILY
BL=ING: ❑ COMMERCIAL
PROJECT IN WTLDLAND ❑ YFS
URBAN N=RFACE AREA ❑ NO
I PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
I IS THE BLDG AN ❑ YES
MCI-= HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:
RECEIVED BY:
By my signature below, I certi fy to each of the following: I am the property ov ner 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 «lith all applicable local
ordinances and state laws relating to uildik� construction. I authorize representatives Of Cupertino to enter the above-identinedprope,,y for inspection pui�)eses.
Signature of Applicant/Agent: Date:
PLEMENTAL INFORMATION REQUIRED
i
OFFICE USE ONLY
❑ OYER -THE -COUNTER
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❑ EXPRESS
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❑ STANDARD
❑ LARGE
❑ MAJOR
tLHP2vliscApp_2011.doc revised 06121111
CITY OF CUPERTINO
IN�91 FEE ESTIMATOR —BUILDING DIVISION
im,ADDRESS:
22406 salem ave.
Plan Check I 0.0 hrs $0.00
DATE: 12/11/2012
REVIEWED BY: bobs.
BP FEES
APN:
BP#:
"VALUATION: 1$2,500
*PERMIT TYPE: Plumbing Permit
1
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Du lex
USE: p
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
propertV line clean out
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Plan Check I 0.0 hrs $0.00
QTY
UNITS
BP FEES
7:'ac. Pei7r,zt 1"c,
Sewer, Building
1PRSEWER
«„z 1:,'t�_. F,��l�.LJ I
1
#
$23
11E'Y1nit f t L':
Supp/. I isp FO-,
PME Unit Fee:
$23.00
PME Permit Fee:
$45.00
Con.Slruc[ion 7CLV.'
F
I
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
1 $23.00
Strong Motion Fee: 1BSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Fewer District, Scnoot
n.....:,.# Tb . ..rn A—v d nn Aho nroliminary infarmatinn availahle and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E .� 711!12)
,tc,_h. Phw)-j t `hcrkPlumb.
Plan Check I 0.0 hrs $0.00
F_7e- Mai
14"ch, Perm;" F,��:
Plumb. Permit Fee: IPPERMIT
7:'ac. Pei7r,zt 1"c,
r,,�;�
Other Plumb Insp. 0.0 hrs $45.00
«„z 1:,'t�_. F,��l�.LJ I
Pi
Phm'h_ , ;,; F'�: _.
Inst, F""'.
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Fewer District, Scnoot
n.....:,.# Tb . ..rn A—v d nn Aho nroliminary infarmatinn availahle and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E .� 711!12)
FEE
QTY/FEE
MISC ITEMS
.Slippl. PC ITE'
PME Plan Check:
$0.00
11E'Y1nit f t L':
Supp/. I isp FO-,
PME Unit Fee:
$23.00
PME Permit Fee:
$45.00
Con.Slruc[ion 7CLV.'
F
I
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes 0 No
$0.00
,1di'ultc°crc/ f'/clrnlirt4r Fccs:
Travel Documentation Fee: ITRA VDOC
$45.00
Strong Motion Fee: 1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
i '` $156.50
$0.00 TOTAL FEE -'F
$156.50
Revised: 10/01/2012