13080192 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10732 CULBERTSON DR CONTRACTOR:TATS INC DBA MR PERMIT NO:13080192
ROOTER PLUMBING
OWNER'S NAME: EVELYNNE MASTON 1260 YARD CT DATE ISSUED:08/23/2013
O ER'S PHONE: 6503631185 SAN JOSE,CA 95133 PHONE NO:(408)271-2822
IrLICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALLJ
License ClassCl(,— Lic.# CO ZS PROPERTLY LINE CLEAN OUT,SEWER LINE
/ REPLACEMENT
Contractor 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
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:$13000
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:37534021.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT WIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WIT 1 0 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 DA OM LAST CALLED INSPE TI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ?
granting of this pe Additionally, plicant understands and will comply Issued by: Date:
with all non-poi sou a regulation per a Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
SignatureDate 3 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.
❑ WNER-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 emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the B rea Air Qua' Management District I
performance of the work for which this permit is issued. will maintain compliance with the pe tiro Mun' ipal ode,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 2 5,25533 and 534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: i 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 PERMIT APPLICATION aa- M E P
Lo COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION b�
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (�b1
CUPERTINO (408)777-3228•FAX(408)777-3333•building(cDcuaertino.org ' ) MISC
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PROJECT ADDRES -G•• J APN# 5-1-5 g�l cv-I
OWNER NAME PHONE L,q-V-stjj-//.$ E-MAIL
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ST ET ADDRESS O�� C Y, FAX
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CONTACT NAME PHONE E-MAII.
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OwNER-BUDDER ❑ 4A R ❑CONTRACTOR AGENT ❑ AR G ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER ICE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS O CITY,SIFT ,ZIP /�.+ PHONE
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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 PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO LOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
Z1004
TOTAL VALUATION: ��Vw RECEIVED BY:
By my signature below,I certify to each of the fo wing: I am the property ownQr 4authdrized.agqLtQAct on the property owner's b alf. I have read this
application and the information I have provided' correc. I have read the D ork a verify it is acl�e�I-a e to co ly with all applicable local
ordinances and state laws relating to building ns I autho' sen ve u ino to enter the above-ide fled pr for inspection purposes.
Signature of Applicant/Agent: A6Date:
SUPPLEME I SMORMATIO QUMED OFFICE USE ONLY
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❑ MAJOR
MEPMiscApp_2011.doe revised 06/21/11
CITY OF CUPERTINO
itsFEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10732 culbertson dr DATE: 08/22/2013 REVIEWED BY: Mendez
APN: BP#: "VALUATION: 1$13,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPS
USE: PERMIT TYPE:
WORK propertly line clean out sewer line replacement
SCOPE
:lfech. flan Check Plumb.Plan Check 0.0 hrs $0.00 Elec..Plan Check
7y,1117,Pernnit Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit Fee:
Other A9ech.Insp. Other Plumb Insp. 0.0 hrs $47.00 Other Elec.Insp.
Alech. Insp,Fee: Plumb.Insp.Fee. Elea,Insp.Fee:
NOTE.This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Theseees are based on the relimina information available and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS(Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 $24.00 IPRSEWER Sewer,Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Construction Tax
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes (j) No $0.00 1 G
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fee: 1TRAVD0C $47.00 Building or Structure
i
Strong Motion Fee: 1BSEISMICR $1.30 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
Non= $140.30 $24.00 $164.30
Revised: 0.7/01/2013