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11100178 (4) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10350 MANN DR CONTRACTOR:ABLE SEPTIC PERMIT NO: 11100178 OWNER'S NAME: MESSMER WALTER J JR AND ELIZAB P O BOX 24819 DATE ISSUED: 10/25/2011 OVl NER'S PHONE: 4082533750 SAN JOSE,CA 95154 PHONE NO:(408)377-9990 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class ��``�� Lic.# �? 7 0 Z- 5 MECH RESIDENTIAL COMMERCIAL r— Contractor Date s? 2 5111 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ABANDON SEPTIC TANK CONNECT TO SANITARY ADD (commencing with Section 7000)of Division 3 of the Business&Professions PROPERTY LINE CLEAN OUT 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. 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 Sq.Ft Floor Area: Valuation:$7000 permit is issued. APPLICANT CERTIFICATION APN Number:32645005.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ; /� Issued by__ Date:��JZ-� j! Signature �h./;1 -Date // r OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 O er or ut orized : forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address cr-'- and expenses which may accrue against said City in consequence of the ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION �:.. all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32645005 . 00 DATE ISSUED. . . . . . . : 10/25/2011 RECEIPT #. . . . . . . . . : BS000015142 REFERENCE ID # . . . : 11100178 SITE ADDRESS . . . . . : 10350 MANN DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MESSMER WALTER J JR AND ELIZAB ADDRESS . . . . . . . . . . : 10350 MANN DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1141 RECEIVED FROM . . . . : ABLE CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407 COMPANY . . . . . . . . . . : ABLE SEPTIC ADDRESS . . . . . . . . . . : P O BOX 24819 CITY/STATE/ZIP . . . : SAN JOSE, CA 95154 TELEPHONE . . . . . . . . : (408) 377-9990 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41. 00 0. 00 41. 00 0. 00 1BCBSC VALUATION 7, 000 . 00 1 . 00 0 . 00 1. 00 0. 00 1BSEISMICR VALUATION 7, 000 . 00 0. 70 0 . 00 0 .70 0. 00 1PPERMITFE FLAT RATE 1. 00 44 . 00 0 . 00 44 . 00 0. 00 1PRSEWER UNITS 2 . 00 44 . 00 0 . 00 44 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 174 .70 0. 00 174 . 70 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING -79 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• building(acupertino.org MISC CUPERTINO PLUMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS L) ^`5� U oo f i ; APN# �� 0 /10 0 OWNER NAME PHONE. E-MAIL I(/(J L . - 75U STREET ADDRESS CITY, STATE,ZIP FAX -7 CONTACT NAME PHONE E-MAIL STREETADDRESS CrtY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BULLDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR N LICENSENUMBER LICENSE TYP13 BUS.LIC# - K Con ?—el COMPANY NAME r -MAII- FAX L ,a � G c .o STREET ADDRESS CTIY,STATE,ZIP PHONE RA ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL. FAX STREET ADDRESS CITY,STATE,ZIP PHONE SE OF fTSFD ar DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE [3 NO EICHLER HOME? ❑NO DESCRIPTION OF WORK J CI 1 TOTAL VALUATION: PO"', RECEIVED BY: By my signature below,f 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 cor ect�J 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 ']ding construction. I authorize representatives of Cupertino to enter the above-identified/property for inspection putimses. Signature of Applicant/Ag Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY THE-COUNTER a ❑ EXPRESS x U w ❑ STANDARD U ❑ LARGE c, ❑ MAJOR MHPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10350 mann dr. DATE: 10/25/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$7,000 -� ',PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK abandon septic tank connect to sanitaryadd property line clean out SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 2 # $44 TOTALS: $44.00 Plumb.Plan Check 0.01 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. OA hrs $44.00Li I NOTE: This estimate does not include fees due to other Departments('tie.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Thesefees are based on the prelinina information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (J"ce Resolution 11-053 Ef'. 7'1/11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 --T Administrative Fee: 1ADMIN $41.00 Work Without Permit? 0 Yes (F) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 i St_rc»�Motion Fee: IBSEISMICR $0.70 Select an Administrative Item Bldgtds Commission Fee: IBCBSC $1.00 SUBTOTALS:, $174.70 $0.001 TOTAL FEE: $174.70 Revised: 10/01/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 16 -Y50 ►�61anr� PERMIT# =tlo(—W OWNER'S NAME: 13.ev' n PHONE# 3 7 7-et 9 j 0 GENERAL CONTRACTOR: 5 BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V 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 Date