13090168 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10671 RANDY LN CONTRACTOR:BAY AREA TRENCHLESS PERMIT NO: 13090168
OWNER'S NAME: KOLLER JOSEPH M AND TERRI D 16690 OAK GLEN AVE DATE ISSUED:09/23/2013
OWNER'S PHONE: 7147579221 MORGAN HILL,CA 95037 PHONE NO:(408)981-5730
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL
License Class Lic.# (0 INSTALL SEWER LINE AND ABANDON SEPTIC TANK
Contractor -7 -
I
-I hereby affirm Z--ti 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:$5500
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:31602045.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT E IBES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITfIIN 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 F M 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 permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
t� RE-ROOFS:
Signature Date /--2 3-1 Q 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 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. 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: 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 � IP
�9MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION (q(l
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 V
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinclecupertino.orp 0 MISC
PLUMBING []MECHANICAL ❑ELECTRICAL []MISCELLANEOUS
PROJECT ADDRESS ('7/ APN# I n OC) s
/06
OWNER NAME ( / �/� PIT - _ 12 E-MAIL
14
al ISTREET ADDRESS CITY, STATE,ZIP FF
CONTACT NAME PHONE TE-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER BUILDER ❑OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LIC�NSFj�I�SB LI ENSE TYPE BUS.LIC#33 lL
COMPANY NAME (O jE-M/� FAX
SJ N sS
STREET ADDRESS n C STATE,ZIP,/'// 7S 7
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 FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK /
f'./'' <w
TOTAL VALUATION: g,
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act onpe owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is ac rate. gree to comply with all applicable local
ordinances and state laws relating to dmg cons n. I authorize representatives of Cupertino to enter the abCove-id tified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTA ORMATION REQUIRED
ON�iz�S
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MEPMiscApp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10671 RANDY LN DATE: 09/23/2013 REVIEWED BY: MENDEZ
APN: BP#: "VALUATION: 1$5,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $24
TOTALS: - Y $24.00
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3U 'a Jay th,2 kP
El am 6 ff M- 01
�.�a �'-'. a �` F,^. � .,'�"'a:,,a .tea 'r �.-..3+ :�:#";z a� s G?t•. s%
L1ech. Plan(,heck Plumb.Plan Check 0.0 1 hrs $0.00 Elec.Plan Check
:Vieth.Permit Fee: Plumb.Permit Fee: 1PPERMIT flee.•.Permit Fee:
Other•Afech.Irtsp. Other Plumb Insp. 0.0 hrs $47.00 Other Elec.Insp.
Gtech.Imp.E''[re Plumb. Insp. Fee: Glee.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc . Thesefees are based on the preffinWha information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS
Plan Chew Fee:
Suppl. PCTce
FT-
PME Plan Check: $0.00
Permit Fee:
Supp/. Insp I'ee
PME Unit Fee: $24.00
PME Permit Fee: $47.00
ConstructionTax.- -F�
Administrative Fee: . IADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITR,4VDOC $47.00
Stron Motion Fee: IBSEISMICR $0.55 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
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Revised: 08/01/2013