13040165 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10368 WESTACRES DR CONTRACTOR:AMERICAN PERMIT NO:13040165
RESIDENTIAL SERVICES OF CA
OWNER'S NAME: MCNUTT PEGGY E AND MICHAEL J T 965 RIDGE LAKE BLVD STE 201 DATE ISSUED:04/23/2013
OWNER'S PHONE: 4084469380 MEMPHIS,TN 38120 PHONE NO:(408)982=0405
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class nn(_3G' Lic.# :-7 G( INSTALL(N)CITY CLEANOUT
Contractor YuieSGv� )Sv Date
I hereby affirm that I 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.
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 SANITAI?Y . .
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:$4900
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:35914016.00 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 SSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for.:inspection purposes. (We)agree to save 180 DA LAST C D INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Z3
granting of this permit. Additionally,the applicant understands and will compl ssu a e:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. --
nn RE-ROOFS:
Signature Date Y 'G I 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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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 requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emir hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I.
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: "�1�Date:
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
GENERAL PERMITAPPLICATION \\10
MER. . .
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORREfAVENUE•CUPERTINO, CA 95014-3255 O
0RQ)777-3228•FAX(408)777-3333•building(ftupertino.org M'I SC ':
III CUPr�RTIIINO '
P'UMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS
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❑OWNER .',OWNER-BUILDERi ❑OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT -
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By my signature below,'I certify to each of the following: I am the property owner or authorized agent to actOgthe property owner's beha a
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 all a le local
ordi iancesland staie laws'relatmg tabuilding construction. I authorize representatives of Cupertino to enter the above-identified property o nspection purposes.
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Signature Of Apphganb?(gent �I Date:
SUPPLEMENTAL INFORMATION REQUIRED
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MEPMiscApp_2011.doc revised 06/21/11
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CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10368 WESTACRES DR DATE: 04/23/2013 REVIEWED BY: MELISSA .-
Igo
APN: 359 14 016 BP#: "'VALUATION: 1$4,900
%PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex7 1 PENTAMATION 1 RPSS
USE: p PERMIT TYPE:
WORK INSTALL N CITY CLEANOUT
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
TOTALS: '.
_ $23.00
W" M No
.,.
;Lfech.flan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
L1ech.Perwit Fee: Plumb.Permit Fee: IPPERMIT Elec. PermitFee:
Fether Alech.Asp. Other Plumb Insp. 0.0 hrs $45.00 Wer Elec.InsP,We"oh.Insp.Fee: Plunib. hish. Fee. Glee.Insp.Fere:
NOTE:This estimate does not include fees due to other Departments(L a Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prefindna information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS(Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Supp/. PCFee
PME Plan Check: $0.00
f erinit Fee:
Suppl.Insp Fee
PME Unit Fee: $23.00
PNffi Permit Fee: $45.00
Consimetion Tax.
Administrative Fee: . 1ADM1N $42.00
Work Without Permit? ®Yes iq No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $45.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$156.50 $0.00 Q $1-56.50
Revised: 04/01/2013
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