13030168CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10355 FARALLONE DR CONTRACTOR: TATS INC DBA MR PERMIT NO: 13030168
ROOTER PLUMBING
OWNER'S NAME: RAJA & KATRINE BHADURY 1260 YARD CT DATE ISSUED: 03/29/2013
OWNER'S PHONE: 4088731920 SAN JOSE, CA 95133 PHONE NO: (408)271 -2822
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALS
License Class Lic. #�76 2 INSTALL 15 ' SEWER LINE UNDER HOME, INSTALL
CLEANOUTS AS NEEDED
Contractor /V I �Y 11® •�-ra� Date A 4C.� Z `'I _ Z01
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division of the Business & Professions AN
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: $4500
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: 36931016.00 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 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 save 180 DAYS FR CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the 29
granting of this permit. Additionally, the applicant understands and will comply Is
at /L�;_
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Z� RE- ROOFS:
Signature Dat�t All roofs shall be inspected prior to any roofing material being installed. If a roof is
o installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER- BUILDER DECLARATION
Signature of Applicant: Date:
I hereb 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 Quality Managemeni 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 5505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date• Z�
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 CONST UCTION 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
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 0V
.10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 �1�
CUPERTINO (408) 777 -3228 - FAX (408) 777 -3333 • buildingla.CUDertino.org
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❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT
CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
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ARCHITECT/ENGINEER NAME
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BUS. LIC #
COMPANY NAME '
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MUI- TI- FAMILY
BUILDING: ❑ COMMERCIAL -
PROJECT IN WI DLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:
RECEIVED BY:
By my signature be ow, I certify to each 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 have pro ' d is correct. I have read the Description of Work and verify it is accurate. I agree to cornply with all applicable local
ordinances and state laws relating to bu' in ction. I a epres fives of Cupertino to enter the above-identified proper y for inspection pu €poses.
Signature of Applicant/Agent: Date: m ej'ck Z_ 9ZO C3
SUPP MENTAL INFORMATION REQUIRED
OFFICE USE ONLY
VER- THE- COUNTER
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❑ EXPRESS
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❑ STANDARD
❑ LARGE
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❑ MAJOR
MEPMisrrlpp_2011.doc revised 06121111
CITY OF CUPERTINO
FFF F,QTTM a TnR — RI TTI .DING DIVISION
APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 1 # $23
TOTALS: $23.00
fe—h. Ilan Check Plumb. Plan Check 10.0 1 hrs $0.00 Elec..Plan C "heck
Fleck Pertnit Pee:: Plumb. Permit Fee: IPPERMIT F.lec. Permit Fee:
Other ,kkch. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elee. Insp
Jllr�ch. lnsp..Fee: Plumb. fish. Fee: Elec. In.T. Fee:
NOTE: This estimate does not include fees due to other Departments (t. e. Planning, runlic woms, rare, aamrary newer'Uisrrlcc, acnuut
District, etc.). These ftes are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'l info,
ADDRESS: 10355 FARALLONE DR
DATE: 03/29/2013
REVIEWED BY: MELISSA
MISC ITEMS
APN: 369 31 016
BP #:
'`VALUATION:
1$4,500
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
PME Plan Check:
PENTAMATION
RPS A
USE:
Permit .Fee:
PERMIT TYPE:
WORK
INSTALL SEWER LINE UNDER HOME INSTALL CLEANOUTS AS NEEDED
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 1 # $23
TOTALS: $23.00
fe—h. Ilan Check Plumb. Plan Check 10.0 1 hrs $0.00 Elec..Plan C "heck
Fleck Pertnit Pee:: Plumb. Permit Fee: IPPERMIT F.lec. Permit Fee:
Other ,kkch. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elee. Insp
Jllr�ch. lnsp..Fee: Plumb. fish. Fee: Elec. In.T. Fee:
NOTE: This estimate does not include fees due to other Departments (t. e. Planning, runlic woms, rare, aamrary newer'Uisrrlcc, acnuut
District, etc.). These ftes are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'l info,
FEE ITEMS (Fee Resolution 11 -053 E . 7if /1/12)
FEE
QTY/FEE
MISC ITEMS
Plan Cheep Fee:
Suppl. PC Fee
PME Plan Check:
$0.00
Permit .Fee:
.Suhpl. Znsp Fee
PME Unit Fee:
$23.00
PME Permit Fee:
$45.00
Consiruction :Tax:
Administrative Fee: 1ADMIN
$42,00
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fees;
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item`.
Bldg Stds Commission Fee: 1BCBSC
$1.00
$156.50 $0.00 $156.50
N ` Revised: 01/01/2013