13020097 r
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1123 KENTWOOD AVE CONTRACTOR:GOGO ROOTER PERMIT NO: 13020097
OWNER'S NAME: GREGORY&MAYUM[DEHAAN TRUSTEE 2530 BERRYESSA RD STE 509 DATE ISSUED:02/19/2013
OWNER'S PHONE: SAN JOSE,CA 95132 PHONE NO:(408)282-7026
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL
3/v
License,Class ` Lie.9 g 3:90 3V REPLACE SEWER LINE TO FOUNDATION LINE
/'�� /��+ CLEANOUT AND
Contractor 5;57(�O �o � Date ' `�� INSTALL PROPERTY LINE CLEANOUT-30 FT
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-insum 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:$8000
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 APN Number:35931008.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and County ordinances and state laws relating WITHIN 180 DAYS O IT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon theabove mentioned property forinspectionpurposes. (We)agreetosave 180 DAYSF ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses whichmayaccrue against said City in consequence of the 2
granting of this permit. Additionally,the applicant understands and will comply Sa Date:
with all non-point source regdati ns perthe mo Municipal Code,Section
9.18. /v/AC/:)rV,j,
_ RE-ROOFS:
Signature Date 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.
❑ 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
1,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 HAZARDOUS MATERIALS DISCLOSURE
constmct 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
1 have and will maintain a Certificate of Consent 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 the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Z
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending 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.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 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1123 Kentwood Ave I DATE: 0211912013 REVIEWED BY: suew/sean
APN: I BP#: 13020097 'VALUATION: $8,000
PERMIT TYPE: PlumbingPermit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION i 11th
USE: p PERMIT TYPE: At
WORKREPLACE SEWER LINE TO FOUNDATION LINE CLEANOUT AND INSTALL PROPERTY LINE
SCOPE CLEANOUT 30 FT
APPLIANCE/EQUIP TYPE FEE H) QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
TOTALS• $23.00 ,ae
is
rR+,s sA via �. 'r,5c,�oll a
xhl. f
Xfech. Plan Check - Plumb.Plan Check 0.0 hrs $0.00 Dec. Plnn Check
:Lfech. Permit Fee:, Plumb.Permit Fee: IPPERA9T Elec. Permit Fee:
other A9ech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec.Insp.
:Meeh. hap. Fee. Phonb. hrsp.Fee: Vec,Insp.Fee,
NOTE:This estimate does not include fees due to other Departments(ice.Planning,Public Works,Fire,Sanitary Sewer District,School
District eta). Thesefees are based on the prelimina information available and are only an estimate. Contact the Dept for addn 4 info.
FEE ITEMS (Fee Resolution 11-053 ff. 7111121 FEE QTY/FEE MISC ITEMS
Plan Chuck Fee:
Slippl. PC Fee
PME Plan Check: $0.00
Pennit Fee:
Suppl. Insp Fee
PME Unit Fee: $23.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: IADMIN
Work Without Permit? O Yes O No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSEISWCR $0.80 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
It 9 li, $156.80 $0.00 {" I TO 'ALSJEE_ $156.80
I.
yoZ QG Revised: 017M/261T/_