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11060200CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 853 FERNGROVE DR OWNER'S NAME: KOLODZIESKI THOMAS T AND KATHE NER'S PHONE: 4088280367 It LICENSED CONTRACTOR'S DECLARATION License Class c— �3 � Lic. # -9(6� `��6— t Contractor M �� Date Z3 r1 1 hereby affirm that 1 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. 1 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 whic,Y� tjrys permit is issued. Q�[�/'�/"J 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 ordinan es and state laws relating to building construction, and hereby authorize represen rues of this city to enter upon the above mentioned property for i spection p oses. (We) agree to save indemnify and keep harmless the Ci Cuperti gainst liabilities, judgments, costs, and expenses which may c e against d City in consequence of the granting of this permit. Ad o y, the a ' ant understands and will comply with all non -point source Municipal Code, Section 9.18. / Signature 6Z Date Li OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: 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) I. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec 7044, Business & Professions Code). 1 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 anon the above mentioned property for inspection purposes. (We) agree to save mnify and keep harmless the City of Cupertino against liabilities, judgments, ,is, 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 CONTRACTOR: TATS INC DBA MR PERMIT NO: 11060200 ROOTER PLUMBING 44777 S GRIMMER BLVD STE C DATE ISSUED: 06/23/2011 FREMONT, CA 94538 PHONE NO: (408)271-2822 BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: REPLACE SEWER LINE, PROPERTid LINE CLEAN OUT Valuation: $5000 AQKl AirlIer: 37539046.00 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WIT OF PERMIT ISSUANCE OR 180 D S CALLED INSPE lop. Issued by: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Cod ,Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I stor r handle hazardous material. Additionally, should I use equipment o evices which azardous air contaminants as defined by the Bay Area uality M amen District I will maintain compliance with the Cupert' 4,� al , Chapter 9.12 and the Health & Safety Code, Sections 25 Owner or authorized agent: Date: 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 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 37539046.00 DATE ISSUED.......: 06/23/2011 RECEIPT #......... BS000013871 REFERENCE ID # ... 11060200 SITE ADDRESS ..... SUBDIVISION ...... CITY ............. IMPACT AREA ...... 853 FERNGROVE DR CUPERTINO OPERATOR: SylviaM COPY # : 1 OWNERKOLODZIESKI THOMAS T AND KATHE ADDRESS 853 FERNGROVE DR CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4636 RECEIVED FROM ....: ADAM COLON CONTRACTOR TATS INC LIC # 23496 COMPANY TATS INC DBA MR ROOTER PLUMBIN ADDRESS 44777 S GRIMMER BLVD STE C CITY/STATE/ZIP ...: FREMONT, CA 94538 TELEPHONE (408)271-2822 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT -- THIS REC NEW BAL ---------- lADMIN ------------- HOURS ---------- 0.50 ---------- 39.00 0.00 39.00 0.00 1BCBSC VALUATION 5,000.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 5,000.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PRSEWER UNITS 1.00 21.00 0.00 21.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 ---------- 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 145.50 0.00 145.50 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT AMOUNT --------------- 145.50 --------------- 145.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- visa VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: '5S3 nn C0 -01/t / OWNER'S NAME: oh e4t, <* 1D ( PERMIT # PHONE # O %a GENERAL CONTRACTOR: Pjdatc'�L BUSINESS LICENSE # ADDRESS:7%? 01%4 riMGV' trtf46A CITY/ZIPCODE: 9y *Our municipal code requires all businesses working in the city to have a airy of Luperrnno Dusa►ess «cease. NO BUILDING FINAL OR FINAL OCCUPANCY INSPP TION(S) WILL SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTVAt,,TORS HAVE INED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: Signature Ifate Please check applicable subcontractors and complete the following information: Owner / Contractor Signature V Z0ate l SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature V Z0ate l CITY OF CUPERTINO VUR` UQr"MA9r(112—RITII.11INf 11TVICTON APPLIANCE / EQUIP TYPE ADDRESS: 853 fern grove dr. QTY/FEE DATE: 06/23/2011 REVIEWED BY: bobs. BP FEES APN: I BP#: "VALUATION: 1$5,000 PERMIT TYPE: Plumbing Permit 1 PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Du lex p PENTAMATION 1 RPSS PERMIT TYPE: USE: PME Unit Fee: $21.00 PME Permit Fee: WORK replace sewer line add property line clean out SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $21 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 TOTALS: A Travel Documentation Fee: IIRA VDOC $21.00 Strong Motion Fee: IBSEISMICR Plumb. Plan Check 10.0 1 hrs $0.00 _ Plumb. Permit Fee: IPPERMIT I I I I Other Plumb Insp. 10.0 I hrs I $42.00 I 1. .1 .z.—,"Unhla n.,.l..ra nnh, nn vctilrlate_ Cnwart the Dent for addn'1 info. FEE ITEMS (1,'ee Resolution 09-051 F:,ff. "'Ll 0) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 A Travel Documentation Fee: IIRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee $39.00 ]ADMIN Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $106.50 $39.00 TOTAL FEE: $145.50 Revised: 04/29/20Y1 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISIC (408) 777-3228 • FAX (408) 777-3333 • building(a�cupertino.org I ICT 02(0 MISCELLANEOUS l MEP PALUMBING M�rECHANICAL hLht_I1ULAL L J �N # OVER-THE-COUNTER PROJECT ADDRESS 71 , N �j_ t c'Y�M-� �/ V �' �� /• Y U OWNERNAmE K RTh at, K� PHONE Lf ' D 412'6 E-MAIL LRE STREET ADDRESS .� G r n C� e- ID ITY, STATE�ZIP � ,PV FAX CONTACT NAMEftCjP ti C a 8'^ I30NEv fj� �� j� E-MAIL STREET ADDRESS � r' U / r -00 { 7, CI STATE, ZIP�� PA -CI rs F ❑ OWER OER-BUILDER NElWN ❑ OWNER AGENT YCO1NTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME �� 6q M L LICENSE NUMBEF Z L -1 L NSE E UU p J ^ 7r 1 BUS. LIC # FAX COMPANY NAME ^ r �( 1 M• '� V ' �PN IVC . E-MAIL STREET ADDRESS (�� CITY TATE,v o -q<f n /� /+ w ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC ##V FAX COMPANY NAME E-MAIL PHONE CITY, STATE, ZIP STREET ADDRESS USE OF Dor DUPLEX ❑ MULTI -FAMILY PROJECT IN WILDLAND [3 YES PROJECT IN ❑ YES URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO BUILDING: COMMERCIAL DESCRIPTION OF WORK Sr.� /tomfelC CbM*yr' C �"�" C JGot rJd �1 TOTAL VALUATION:SO By my signature below, I certify to each of the application and the information I have prow' ordinances and state laws rerating to g < Signature of Applicant/Agent RECEIVED BY: e pro ow r or authorized agent to act on the prop"owner's behalf. I have read this I have a cri on of Work and verify it is accurate. I agree to comply with all applicable local t onze re ese tives of Cupertino to enter the above-I'dgntified propfor inspection putposes. 'ViyDate: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER F ❑ EXPRESS Y U STANDARD RD U QG LRE 1AJO❑1 MEPMiscApp_2011.doc revised 06121111