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13060055CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10744 BROOKWELL DR CONTRACTOR: ABC PLUMBING AND PERMIT NO: 13060055 DRAIN OWNER'S NAME: CATHERINE JOHNSON P O BOX 21632 DATE ISSUED: 06/07/2013 OWNER'S PHONE: 4082552963 SAN JOSE, CA 95151 PHONE NO: (408)234-8134 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALEI ❑ LICENSED CONTRACTOR'S/DECLARATION License Class ` Lich# REPLACE (E) SEWER LINE FROM BUILDING TO ContractorERTY �,#e pGU �/ F � 7 /12LINEP, INSTALL (N) CLEANOUT I hereby affirm that I am licensed under the provisions o 'Cha ter 9 (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: $4500 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 36921039.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this 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 property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses w ' may accrue against said City in consequence of the Date: hb granting of this pe it. dditionally, the applicant understands and will comply er the Cupertino Municipal Code, Section wiW,m 9. 7% RE-ROOFS: Si Date All roofs shall be inspected prior to any roofing material being installed. If a roof is 14 installed without first obtaining an inspection, I agree to remove all new materials for inspection. El OWNER-BUIaR DECLARATION Signature of Applicant: Date: I h eby 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 emit 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. I have and will maintain Worker's Compensation Insurance, as provided for by will maintain compliancewith the C ino Mun' p de, Chapter 9.12 and the Health & Safety Code, ctio 0 25533 34. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized age' . 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 CO RUCTION LEND GENCY 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 I hereby affirm that there4/a 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 may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this pe it Additio ally, the applicant understands and will comply with all non -poi s rce re ations per the Cup 'no Municipal Code, Section Licensed Professional 9.18. / Signatur Date u GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION O 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (� CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.org V MISC PLUMBING n MECHANICAL n ELECTRICAL n MISCELLANEOUS _ PROJECT ADDRESS �(� %J Q/j� G PA- APN # -369 r -7 ' 2 V OWNER NAME j�7 0At PHONE 4ea0- g f-5-- ZT 9 -MAAIL 7 STREET ADDRESS C ^ u L 7 fT /•l G CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX �� ❑ OWNER ❑ OWNER -BUILDER 11OWNERAGENT -L-! CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME ,,- LI CENSE NUMBERi�,f5-� (O ^�L LICENSE TYPE �r 2/ 7 4 BUS. LIC# COMPANY NAMEV �i ��Y � 4/ t� � FAX STIFTD CITY, STATE, ZIP G/�( Je? p / C-- PHONE �/p •fir J 72 ^Z [# ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK G ri - )�j� ^ Xi5fC7- �26 gVle sm/ yr e o TOTAL VALUATION:L�SC/D DBY: By my signature below, I certify to each of the following) I am the property owner or authorized agent to ac e p perty owner' ave read this application and the information I have provided is corceft�e read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b ' g truction. u e representatives of Cupertino to enter the above-identifie to rty4b, inspection purposes. Signature of Applicant/Agent: Date: {/A PLEMENTAL INFO ATION REQUIRED OFFICE USE 'ONLY W OVER-THE-COUNTER ❑ EXPRESS U a ❑ STANDARD: ❑ LARGE ❑ MAJOR MEPMiscApp_201 Ldoc revised 06/21/11 73 CITY OF CUPERTINO 1�� FF.F. FCTIMATnR — RITII.DING DIVISION APPLIANCE/ EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $23 TOTALS: $23.00 Xtech. Flan Check Plumb. Plan Check 10.0 1 hrs $0.00 Elec. Plan ('heck Lleclt. Permit Fee: Plumb. Permit Fee: IPPERMIT Llec. Permit Fee: Other ,ttech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Insp. Allech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee: NOTE: This estimate does nottinctude fees due to other uepartmems (Le. riammng, ruouc rrorKs, rtre, aunuury newer "imriuy ouisuus Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) ADDRESS: 10744 BROOKWELL DR DATE: 06/07/2013 REVIEWED BY: MELISSA 1w, APN: 369 21 039 BP#: *VALUATION: 1$4,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex p PME Plan Check: PENTAMATION 1 RPSS USE: Pe rima I ee: PERMIT TYPE: A WORK REPLACE E SEWER LINE FROM BUILDING TO PROPERTY LINE INSTALL N CLEANOUT SCOPE PME Unit Fee: APPLIANCE/ EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $23 TOTALS: $23.00 Xtech. Flan Check Plumb. Plan Check 10.0 1 hrs $0.00 Elec. Plan ('heck Lleclt. Permit Fee: Plumb. Permit Fee: IPPERMIT Llec. Permit Fee: Other ,ttech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Insp. Allech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee: NOTE: This estimate does nottinctude fees due to other uepartmems (Le. riammng, ruouc rrorKs, rtre, aunuury newer "imriuy ouisuus Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC I''eea PME Plan Check: $0.00 Pe rima I ee: ;Suhx�l..Ins� Fee� PME Unit Fee: $23.00 PME Permit Fee: $45.00 Construction Tent: Administrative Fee: 1ADMIN $42.00 Work Without Permit? ® Yes 0 No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item 1 Bldg Stds Commission Fee: 1BCBSC 1 $1.001 -� $156.50 $0.00` $1 56.50 0. Revised: 04/29/2013