13080154614
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20930 FARGO DR
CONTRACTOR: TATS INC DBA MR
PERMIT NO: 13080154
ROOTER PLUMBING
OWNER'S NAME: SUNIL K SHRIVASTAVA
1260 YARD CT
DATE ISSUED: 08/21/2013
OWNER'S PHONE: 6503918451
SAN JOSE, CA 95133
PHONE NO: (408)271-2822
JOB DESCRIPTION: RESIDENTIAL COMMERCIALS
Ef LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # t1-- ,z4f)
REPLACE (E) SEWER LINE WITH (N) TRENCHLESS
�Q ,(p,�•
��Or"' Date g 2 I�l
SYSTEM
& INSTALL 2 PROPERTY & FOUNDATION CLEANOUTS
Contractor y''
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
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: $6800
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 32630113.00
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
the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM ED INSPECTION.
upon
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
City in consequence of the
Q n
costs, and expenses which may accrue against said
I Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature�3
RE -ROOFS:
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,
wilt 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. 1 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.
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
Section 3700 of the Labor Code, for the performance of the work for which this
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:�1•C%��.Gt Gr/Yte:�
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
CONSTRUCTION LENDING AGENCY
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 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
RM
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GENERAL PERMIT APPLICATION /
., MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION O
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 Ov
CUPERTINO (408) 777-3228• FAX (408) 777-3333 • building(d-)cupertino.org 141 misc
PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS'�
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT Q CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONT ORNAME
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LICS�$It��
LICENSE TYPE
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EMAIL
FAX
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
EMAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX
❑ MULTI -FAMILY
PROJECT IN WHALAND ❑ YESPROJECT
IN ❑�-7YES
IS THE BLDG AN ❑ YES
BUILDING: COMMERCIAL
URBAN INTERFACE AREA NO
FLOOD ZONE p( NO
EICHLER HOME? NO
DESCRIPTION OF WORK
XI
TOTAL VALUATION: /
v V
REC Y: "
By my signature below, I certify to each of the following: I am the property owner or auth agent to act property
have read this
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 with all applicable local
ordinances and state laws relating t ding construction. I au orize Wresentatives of Cupertino to enter the above -identified roperty for inspection purposes.
Signature ofApplicant/Agent:
Date: 3
821��
SUPPLEMENTAL INFORMATIONREQUIRED
OFFICE USE ONLY
W
VER -THE -COUNTER
❑ EXPRESS
WV
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❑ STANDARD
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❑ LARGE
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❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
rr�n r, orrFAN A Tl1D MTTT ."TT%TV TIIVIRION
APPLIANCE / EQUIP TYPE
A'AUXU Lu1111L:sv
ADDRESS: 20930 FARGO DR
- — -- -
DATE: 08/21/2013
REVIEWED BY: MELISSA
UNITS
APN: 326 30 113
BP#:
"VALUATION: $6,800
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or Duplex
#
PENTAMATION 1 RPSS
PERMIT TYPE: i
WORK
REPLACE E SEWER LINE WITH N TRENCHLESS _SYSTEM & INSTALL 2 PROPERTY &
SCOPE
FOUNDATION CLEAN OUTS
APPLIANCE / EQUIP TYPE
FEE ID
-- --_ _-- _
QTY/FEE
QTY
UNITS
BP FEES
Sewer, Building
1PRSEWER
1
#
$24
Sewer, Sanitary
1PRSEWER
Suppl. Insp Fee
1
#
$24
PME Unit Fee:
$48.00
PME Permit Fee:
$47.00
Conslr-uc lion :Tax:
Administrative Fee: IADMIN
$44.00
Work Without Permit? ® Yes (E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
Xle.c,h. Plan (:'heck Plumb. Plan Check 0.0 hrs $0.00 Elec. flan Check
--Wech. Permit Fee: Plumb. Permit Fee: IPPERMIT laec. Permit Fee:
Other ;Tlech. Insp, Other Plumb Insp. 0.0 hrs $47.00 Other Elec. Insp.
llech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Flee:
m__,__ cs_- a,... . Q,.. . rl;of—t Q7.7
NOTE: This estimate does not tnctuaejees aue ro orneruepursrnengs (tie. K.wt,&•,.s, _ -�.. �• - • �� - __.. _- _ __- -,
,. ___- __�______.•_._ _..:r r r ,., r .., ,..,r„ .,., o�r.w,nto Cnntart the Dent for addn l info.
Utstrlct, ere. . hese ees are ve— ors use •us,iasw.
FEE ITEMS (Fee Resolution 11-053 E . 7f 11112,)
•,..,•••.»..�,. ».____
FEE
-- --_ _-- _
QTY/FEE
_ --
MISC ITEMS
Plan Check Fee:
Supjpl. PC.'.Fee>
PME Plan Check:
$0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee:
$48.00
PME Permit Fee:
$47.00
Conslr-uc lion :Tax:
Administrative Fee: IADMIN
$44.00
Work Without Permit? ® Yes (E) No
$0.00
Advuncecl Planning Fees:
Travel Documentation Fee: ITRA VDOC
$47.00
Strong Motion Fee: IBSEISMICR
$0.68
Select an Administrative Item
$0.00 A aEE $187.68
kik P ti A, §r"aft `ry^
Bldg Stds Commission Fee: IBCBSC
�{r� x$187.681
$1.00
Revised: 07/01/2013