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11040057 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10480 STOKES AVE CONTRACTOR:GOGO ROOTER PERMIT NO: 11040057 OWNER'S NAME: KUNDRACIK MICHAEL JR AND BEVER 2530 BERRYESSA RD STE 509 DATE ISSUED:04/08/2011 OWNER'S PHONE: 4082552374 SAN JOSE,CA 95132 PHONE NO:(408)282-7026 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# 43 7 d 3q F MECH RESIDENTIAL COMMERCIAL Contractorntw n r;-e -tde_t4 Date ! I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SEWER MAIN REPAIR (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. Ll 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. S Ft Floor Area: Yat' 'on:$4387 1 have and will maintain Worker's Compensation Insurance,as provided for by q ? j ^ Section 3700 of the Labor Code,for the performance of the work for which this , permit is issued. APN Number:32640 � . ' Occupancy Type: APPLICANT CERTIFICATION 3x 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 E EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save IN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,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 Issued by: Date: 9.18. Signature Date 14l /if RE-ROOFS: C OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the P Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Owner thorized agent: Compensation laws of California. If,after making this certificate of exemption,I Date• (• 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION C and expenses which may accrue against said City in consequence of the ng of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wizen all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10480 stokes ave DATE: 04/08/2011 REVIEWED BY: APN: BP#: "VALUATION: 1$4,387 y°PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: woRK sewer main repair SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $21 TOTALS: $21.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs 1 $42.00 , NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS the Resolution 09-05.1 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 G No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Stronf Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg= Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: F$106.501 $0.00 TOTAL FEE: $106.50 Revised: 03/01/2011 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32647026. 00 DATE ISSUED. . . . . . . : 04/08/2011 RECEIPT #. . . . . . . . . BS000013136 REFERENCE ID # . . . : 11040057 SITE ADDRESS . . . . . : 10480 STOKES AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : KUNDRACIK MICHAEL JR AND BEVER ADDRESS . . . . . . . . . . : 10480 STOKES CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1247 RECEIVED FROM . . . . : SERIGO ALVAREZ CONTRACTOR . . . . . . . : DUARTE TADEU LIC # 28801 COMPANY . . . . . . . . . . : GOGO ROOTER ADDRESS . . . . . . . . . . : 2530 BERRYESSA RD STE 509 CITY/STATE/ZIP . . . : SAN JOSE, CA 95132 TELEPHONE . . . . . . . . : (408) 282-7026 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 387 .00 1. 00 0. 00 1.00 0. 00 1BSEISMICR VALUATION 4, 387.00 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 106 .50 0. 00 106.50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 106.50 VISA --------------- TOTAL RECEIPT 106 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING 6L GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•building(Mcupertino.org misc CUPERTINO PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS t ,�/I ' 0 2 LU/ ""C' &e APN# �� 02– OWNER " Z OWNER NAME �{ / (G PHONE MAM i�" 4 "( Svc STREET ADDRESS C/ Ave CITY, STATE,ZIP r� C�� /,�7! FAX CONTACT NAME J t (/l PHONE (' YF-- yMAIL,(/ STREET ADDRESS 'C C t cJ(! CITY,STATE,ZII' t (� { C ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT lzYCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHffECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME �e raC e-7 LICTE NUMBER LICE?E TYPE BUS.LIC# � Gv0Ca COMPANY NAME E-MAIL FAX 6 STREET ADDRESS J ! u n � CITY.STATE.ZIP qoq d �� PRONE 2 —7 ARCHITECT/ENGINEER NAME F LICENSE NUMBER BUS.LIC#/ COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF P--SJF_D or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes No FLOOD ZONE ❑ Yes NO DESCRIPTION OF WORK TOTAL VALUATION: �7t 6 nRECEIVEDBY u ; By my signature below,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 provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to build' construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: PPLEMENTAL INFORMATION REQUIRED Nn r� C T RGr _ += MEPMiscApp_201 1.doc revised 03/16/11