13040152 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7876 BELKNAP DR CONTRACTOR:GOGO ROOTER PERMIT NO:13040152
OWNER'S NAME: BARON STEVEN W AND KATI 2530 BERRYESSA RD STE 509 DATE ISSUED:04/22/2013
OWNER'S PHONE: 4084991237 SAN JOSE,CA 95132 PHONE NO:(408)282-7026
LICENSED CONTRACTOR'S DEECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIALE]
License Class� Li..# ( 3 / L/ INSTALL PROPERTY LINE CLEAN OUT
Contractor V U G C 9- Date y
I hereby affirm that I am licensed under the provisions o Chapter
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect. SANITARY
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:$5500
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:36210040.00 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 roperty for.inspection purposes. (We)agree to save 180 DAYS F CALLED INSPECTION.
indemnify and keep h e of Cu ' o against liabilities,judgments,
costs,and expens whic may accru s s 'd City in consequence of the 2�, ?
granting of thi ermit. Additio y nderstands and will comply Iss y: Date:
with all no oint source re atio . p Cupertino Municipal C e,Section
9.18.
RE-ROOFS:
Signatu 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.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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 requireme er Chapter 6.95 of the
California Health&Safety Code,Sections 25 25533, d 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupert' unicip 1 e, hapter 9.12 and the
declarations: Health&Safety Code,Section 25 (a)shoul store or a e hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,shout use equi nt or d . es whi emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defin y the Ba rea A' ality Ma agement District I
performance of the work for which this permit is issued. will maintain complian with the pertino nici al C e,Chapter 9.12 nd
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety de,Sectio s 25 553 ,
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen D
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 CONSTRUCTION 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
OENERAL PERMIT APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
Sci.,
it
1830Q TORRE AVENUE CUPERTINO, CA 95014-3255
777-3228•FAX(408)777-3333•buildingCa2cupertino.org
CUPERTIINO M:'
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PLUMBIN.Cr ❑MECHANICAL
]ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS I Y, APN# �7 I O 0 L(/l
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STREET ADDRESS �y pp.� CITY,STATE,ZIP FAX
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CONTACT NAME PHONE E-MAI,
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER C7.OWNER-BUILDER " ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT.
CONTRP CTOR N LICENSE ER LICENSE TYPE BUS.LIC#
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COMPANY NAME E-MAIL FAX
STREET ADDRESS 16 FU ��CV" A CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER!NAME / LICENSE NUMBER BUS.LIC#
COMPANY NAME, E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
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USE Of: ❑ISFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND [I YES PROJECT IN ❑YES IS THE BLDG AN - ❑.YES
BUTAIN r 1_ ❑COMMERCIAL :: , URBAN INTERFACE AREA [j NO - FLOOD ZONE ❑NO EICHLER HOME? ❑NO
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By my slgnattue be�Ow,I'certify tote ach of the follo I am th ertyowner or autho ed agent to act on ope o a f. I h ve read this
application and the information I have provided orrect. I read a Description of Wo and verify it is accurate. I agre to comply with applicable local
ordinancesland.state I�ws relating tq;build' constm I thor' representati pemno to enrerme above-identified pr rty for i ection purposes.
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SlgnattYTe gt,401�an�/Agent: I' Date: L 2
SUPPLEMENTAL INFO
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MEPMiscApp_2011.doc revised 06/21111
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CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 7876 BELKNAP DR DATE: 04/22/2013 REVIEWED BY: MELISSA
APN: 36210 040 BP#: *VALUATION: 1$5,500 1
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS
WORK INSTALL PROPERTY LINE CLEAN OUT
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
TOTALS: $23.00
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a�
1tech.Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Nkch.Permit Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit Fee:
01her Afech.Insp. Other Plumb Insp. El
hrs $45.00 CJther Elec.Insp, ET-1-
Alech.Insp.Fee: Pfumh. Insp.Fee: Elec,Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le,Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the prellmniina information available and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS ffee Resolution 11-053 E . 7/1/121 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl.PC Fee
PME Plan Check: $0.00
Perin it.Fee..•
Suppl. Insp Fee
PME Unit Fee: $23.00
PME Permit Fee: $45.00
Construction Tear: F I
Administrative Fee: IADAffN $42.00
Work Without Permit? ® Yes (j) No $0.00
,dva.nced Planning Fees:
Travel Documentation Fee: ITRA VDOC $45.00
Strong Motion.Fee: 1BSEISMICR $0.55 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$156.55 $0.00 � -,�° $156.55
` Revised: 04/01/2013
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