13040055 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22442 CARNOUSTIE CT CONTRACTOR:ABLE SEPTIC PERMIT NO:13040055
OWNER'S NAME: JOSEPH SEGNA P O BOX 24819 DATE ISSUED:04/05/2013
OWNER'S PHONE: 6504446385 SAN JOSE,CA 95154 PHONE NO:(408)377-9990
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11COMMERCIALE]
License Class ` Lic.# PROPERTY LINE CLEAN OUT,15"INC SEWER LINE
Al REPAIR
Contractor L/ Date
1 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 consen fAce,
rker
Compensation,as provided for by Section 370 e th
performance of the work for which this permi ' is 1 a: Valuation:$3200
I have and will maintain Worker's Compensat ide r
Section 3700 of.the Labor Code,for the performance of the work for which this APN Number:35603028.00 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 andcourty ordinances and state laws relating WITHIN 0 AYS OF PERMIT ISSUANCE OR
to building construction,and hereby anIthoriie.representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA F M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino againstliabilities,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 Issued by: Date:
with all non-point sour regulations per the Cupertino Municipal Le, tion
9.18.
RE-ROOFS:
Signatur 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)
1,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 Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the C ertino Municipal Code,Chapter 9 12 nd
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec'o 505,25533,and 25534.
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 whichmay 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 C
• MEP
10 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DI
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(cDcupertino.org misc
I
®PLUMBING EIMECHANICAL ❑ELECTRICAL [—]MISCELLANEOUS
PROJECT ADDRESS 27,441 C o►rnan s h c L APN#
OWNER NAME1f1� PHONE �q.�5 �� E-MAIL
STREET ADDRESS /�^ �i f ,` I CITY, STATE,ZIP A FAX
CONTACT NAME CI `-L -1 u PHONE V1 E-MAIL
STREET ADDRESS CITY,STATE,ZIP CU FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 8I CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER u j I LICENSE TYPE -41
BUS.LIC#
COMPANY NAME N+� &MAIL �I �' Won FAX _(Uj !I"
STREET ADDRESS j,`U �f� Crt Y ST. 4 ,` �O PHONE /M�f
ARCHITECTIENGINEER NAME LICENSE NUMBER V VV BUS.LIC# 't
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF IN SFD o DUPLEX ❑ MULTI-FAMQ;Y PROJECT IN WIIALAND ❑ YES PROTECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA �.NO FLOOD ZONE ❑NO EICHLERHOME? NO
DESCRIPTION OF WORK J I
TOTAL
VALUATIO REC
By my signature below,I certify to each of the following: I am the property owner or authorized agent to an property owner's behalf. I have read this
application and the information I have prov' is correct. I have read the Description of Work and verify it iS e. I ee to comply with all applicable local
ordinances and state laws relatin truction. I authorize representatives of Cupertino to enter the a-id /tified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPP TAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
ae .
❑ EXPRESS
v
❑ sTnxnnRn
❑ LARGE
a
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 22442 carnoustie ct DATE: 04/05/2013 REVIEWED BY: Mendez
APN: BP#: "VALUATION: $3,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPDP
USE: p PERMIT TYPE:
WORK ro grtV line clean out 15 inc sewer line repair
SCOPE
2 51 M11101_61 1111011,
�Lte A Plan Check � Plumb.Plan Check 0.0 hrs $0.00 Glee.Plan Check
iLlech.Permit Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit Fee:
L,1111111�
�lfech.Insp. Other Plumb Insp. 0.0hrs $45.00 0/her Elec.Insp.
Insp. fee: Plurnb. Insp. £ee: 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 prolimina information available and are only an estimate Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl.PC Feer Q Reg. .0 OT 0.0 hrs $0.00 $45.00 IPREPPIPE Piping,Area
PME Plan Check: $0.00 F-1-1 # Plumbing
Permit Fee: $0.00 $23.00 IPRSEWER Sewer, Sanitary
Suppl. Insp.Feer Reg. 0 OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Conswuction Tcix: FA
Administrative Fee: IADMIN $42.00 0
Work Without Permit? 0 Yes (E) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential (F)
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure.
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldy,Stds Commission Fee: IBCBSC $1.00
$133.50 $68.00 * $201.50
Revised: 04/01/2013