10080057 CITY OF CUPERTINO BUILDING PERMIT
WILDING ADDRESS: 10160 LEBANON DR CONTRACTOR:TATS INC DBA MR PERMIT NO: 10080057
ROOTER 3LUMBING
'WNER'S NAME: KAREN CALDWELL 44777 S GRIMMER BLVD STE C DATE ISSUED:08/09/2010
.,NER'S PHONE: 4082521177 FREMONT,CA 94538 PHONE NO:(408)271-2822
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
icense Class L Lic.# 7�6,;t�2 MECH r RESIDENTIAL r COMMERCIAL r
'ontractor/� C�(J ► Date
JOB DESCRIPTION:REPLACE APPRX 60'OF 4"WASTELINE FROM PROPERTY
hereby affirm that I am licensed under the provisions of Chapter 9 LINE TO E UILDING WITH SDR 17 PIPE WITH TRENCHLESS
:ommencing with Section 7000)of Division 3 of the Business&Professions SYSTEM I JCLUDE CITY CLEANOUT AND HOME CLEANOUT
'ode and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
have and will maintain a certificate of consent to self-insure for Worker's
'ompensation,as provided for by Section 3700 of the Labor Code,for the
erformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Flo,)r Area: Valuation:$7000
ermit is issued.
APPLICANT CERTIFICATION APN Number:34214019.00 Occupancy Type:
certify that I have read this application and state that the above information is
orrect.I agree to comply with all city and county ordinances and state laws relating
building construction,and hereby authorize representatives of this city to enter
pon the above mentioned property for inspection purposes. (We)agree to save PEF.MIT EXPIRES IF WORK IS NOT STARTED
idemnify and keep harmless the City of Cupertino against liabilities,judgments,
osts,and expen which may accrue against said City inconsequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ranting of
' permit. Addition y,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
n
rith all nooint sour regul ons per the Cupertino Municipal Code,Section
.18.
Z_D Issued b3: Date:
i--nature Date
O ER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of All roofs s call be inspected prior to any roofing material being installed.If a roof is
he following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
as owner of the property,or my employees with wages as their sole compensation, inspection.
411 do the work,and the structure is not intended or offered for sale(Sec.7044,
lusiness&Professions Code) Signature of Applicant: Date:
as owner of the property,am exclusively contracting with licensed contractors to
onstruct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
eclarations: HAZARDOUS MATERIALS DISCLOSURE
have and will maintain a Certificate of Consent to self-insure for Worker's
'ompensation,as provided for by Section 3700 of the Labor Code,for the I have rea 1 the hazardous materials requirements under Chapter 6.95 of the
erformance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
ection 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
ermit is issued. contaminf nts as defined by the Bay Area Air Quality Management District I will
certify that in the performance of the work for which this permit is issued,I shall maintain(ompliance withAe Cupertino Municipal Code,Chapter 9.12 and the
of employ any person in any manner so as to become subject to the Worker's Health& 3 egeagen
ions 25505,25533,and 25534.
'ompensation laws of California. If,after making this certificate of exemption,I
ecome subject to the Worker's Compensation provisions of the Labor Code,I must Owner4r : D r/ /)
)rthwith comply with such provisions or this permit shall be deemed revoked. Date: v
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
certify that I have read this application and state that the above information is I hereby at firm that there is a construction lending agency for the performance of work's
orrect.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
building construction,and hereby authorize representatives of this city to enter Lender's Name
-,n the above mentioned property for inspection purposes.(We)agree to save
unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's,►ddress
._ts,and expenses which may accrue against said City in consequence of the
ranting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
rith all non-point source regulations per the Cupertino Municipal Code,Section
.18. 1 understar d my plans shall be used as public records.
ignature Date Licensed Professional
CITY OF CUPEF.TINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot .
APN . . . . . . . . : 3421401S .00
DATE ISSUED. . . . . . . : 08/09/2C10
RECEIPT #. . . . . . . . . : BS000011122
REFERENCE ID # . . . : 1008005/
SITE ADDRESS . . . . . : 10160 LEBANON DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER KAREN CP.LDWELL
ADDRESS 10160 LEBANON DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : KAREN CPLDWELL
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
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 7, 000. 00 1 . 00 0 .00 1. 00 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 .00 0.00 106. 00 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 106 . 00 #1025
---------------
TOTAL RECEIPT 106 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF CUPE RTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10160 Lebanon Dr. DA7 E: REVIEWED BY:
APN: BP#: *VALUATION: 1$7,000
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex 101111, APPLICATION 1 RPSS
USE: C'I.E�C)K�ih[.��: TYPE:
as
cc
3 �
APPLIANCE/EQUIP TYPE CAPACITY FLR AREA QTY BP FEES
s.f.
Sewer, Sanitary 1PRSEWER 1 $21
TOTALS: F $21.00
Plumb.Plan Check 0.0 hrs
$0.00
[Plumb.Permi.Fee: IPPERMIT 1"7C( f'e fnlr FL,,
77 Other Plumb Insp. 0.0 Fhrs $42.00
NOTE. Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolulion 09-051 F.f: 7.,'1129) FEE QTY/FEE MISC ITEMS
Mail Chcc•i, F c.
PME Plan Check: $0.00
1'c�trti?77Ict.
PME Unit Fee: $21.00
PME Permit Fee: $42.00
(',JYt,s ru, t;olt o-,,
.`iCC)ll,t/C£Ft IL'i'tE`l('
Work Without Permit? Q Yes (D No $0.00
1'tcrt tr Iw I`c c"
Travel Documentation Fee: ITRA VDOC $42.00
'rJr�,r �2r,tivtr /'fSelect an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $106.001 $0.00 TOTAL FEES $106.00
Revised: 8/06/2010
r.
CITY OF CUPERTINO
REPIPE/SEWER/MAJN SERVICE
UPE T
C iZ.1NO PERMIT APPLICArCION FORM
Date: Q G
APN # — I
Building Address: ` )
Phone#:
Ow er's Name: L L C�
L q
Phone#:840 l _ TT O.¢
Contrac or: ® Fax#:
Phone(5107 Jr-
Contact:
FR A0 RA,LL- N)A Fax #:
Contractor License#: �� & 5
Cupertino Business License#: /Of-
Job Description: Re
le �a j�P r�c� �`I vt� C�
Goma�f-e l:we ► v 0-4- Pm P1 �' '�'� s s4-e ►J C,`
lull,
Residential -$4
Commercial ❑
Valu a 'on: V
0
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set& the sheet index.
Green Building Points:
rTee ID Fee Description Fee Permit Type
Grou
PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer .�.
1BPREPIPE Commercial re-pipe Fer fixture # P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards C ommission-. B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09