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13030133 .CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10096 LAMPLIGHTER SQ CONTRACTOR:CONSOLIDATED PERMIT NO: 13030133 PLUMBING INC OWNER'S NAME: RUTH DONNA L 3732 CHARTER PARK DR STE D DATE ISSUED:03/25/2013 OWNER'S PHONE: 408559197.7 SAN JOSE,CA 95136 PHONE NO:(408)978-3093 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL II License Class4� S6 Lic.# /,6 Z... REPLACE(E)SEWER LINE FROM HOUSE FIXTURE TO PROPERTY LINE&INSTALL(N)PROPERTY LINE ContractorDate CLEANOUT I hereby affirm that I am licensed unde a provisions of Chapter 9 (commencing with Section 7000)of Division Sof 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 hANITARY 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:$20000 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:34233002.00 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 cityand'county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save180 DAYS FROM LA I.ED INSPEC_TION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Z S/13 granting of this permit. Additionally,the applicant understands and will comply ssu Date: with all non-point sourceejcklati ons per Cupertino Municipal Code,Section 9.18. 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 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 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 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 Qv3lity Management District I performance of the work for which this permit is issued. will maintain compliance woCtinoal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance'as provided for by the Health&Safety Code,S 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ag t: 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. It aftermaking 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 perrnit 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 theabove 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 GENERAL PERMIT APPLICATION p MER COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION M .10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 0 CUPERTINO (408)777-3228• FAX(408)777-3333• building cDcuoertino.org \M MISC [:]PLUMBING ❑MECHANICAL [—]ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS rs APN# v OWNERNAME PH y� l MAII STREET ADDRESS CITY, STATE,ZIPe� MEOW FAX CONTACT NAME PHON�F O —9 7 _360 E _.-MPIL STREET ADDRESS 37 CITY,STATE,ZIP JFAX' ❑ O)VNER ❑ OWNER-BUILDER ❑ O)hWER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGJI.'EER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME a K S LICENSE NUMBER +` LICENSE TYPEZ,_3 BUS.LIC# COMPANY NAME * E-MAIL �J5 1 FAX 0A1_6&1j aLd STREET ADDRESS CITY,STATE,ZIPfo� �� PHONE s ARCHITECT/ENGINTEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULn-FAMILY PROJECT IN\N91DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONT ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK IF TOTAL VALUATION: O©�� G� RECEIVED By my signature below,I certify to each of the owing: I atn�h prope caner or authorized aeent to'act the a alf. I have read t s application and the information I h ovided is co ect. I ve rea escription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws rela' to build- g cot trio I a ___Te of Cupertino to enter the above-identified rro�pefty for inspection puQposes. Signature of Applicant/ ent: Date: P SUP EMEk4 INFO ON REQUIRED OFFICE USE ONLY VER-THE-COUNTER r' ❑ EXPRESS U u ❑ STANDARD U ❑ LARGE a ❑ MAJOR MEPATiscApp_2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION VADDRESS: 10096 LAMPLIGHTER SQ DATE: 03/25/20137REVIEWED BY: MELISSA 342 33 002 BP#: *VALUATION: $20,000 *PERPlumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 RPSS USE: p PERMIT TYPE: WORK REPLACE E SEWER LINE FROM HOUSE FIXTURE TO PROPERTY LINE & INSTALL N SCOPE PROPERTY LINE CLEANOUT APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $23 TOTALS: $23 00 Ife(A.Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check FfechPermit Fee: Plumb.Permit Fee: IPPERmT Elec.Permit Fee: [Afi"ch. Meeh.Insp. F-1 17 Other Plumb Insp. 0.0 hrs $45.00 Other Elec.Insp. Li Insp..Fee: Plumb. hasp.Fee: Elec.Insp.Fee: NOTE.This estimate does not include fees due to other Departments(Le,Planning,Public Works,Fire,Sanitary Sewer District,School District etc). Theseees are based on the prefindna information available and are only an estimate Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Stipp 1. PC Fee PME Plan Check: $0.00 Pertnit Fee: Suphl. Insp Fee PME Unit Fee: $23.00 PNM Permit Fee: $45.00 Construction Tax: Administrative Fee: IADMIN $42.00 Work Without Permit? ®Yes. (F) No $0.00 Advanced Planning Fees: Travel Documentation Fee:. 1TRAVDOC $45.00 Strong Motion Fee: IBSEISMICR $2.00 Select an Administrative Item BldpStds Commission Fee: IBCBSC $1.00 21 $158.00 $0.00 $158.00 Revised: 01/01/2013