13090022 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 5923 BOLLINGER RD CONTRACTOR:5o(i T)4 3 q,4 PERMIT NO:13090022
rb)M B I N
OWNER'S NAME: TUAN NGUYEN DATE ISSUED:09/05/2013
OWNER'S PHONE: 4087262665 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL0
License Class Lic.# 1 S (- REPLACE(E)MAIN WATER LINE FROM FOUNDATION
(� I, TO
Contractor SGU� ny7IT UIK�9,"I'late PROPERTY LINE
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.
r, 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:$2100
1 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:37535021.00 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 so 4IT 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 1 L LED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Q
costs,and expenses which may accrue against said City in consequence of the Issued Date: ! 3
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.
s RE-ROOFS:
Signature` �� ` Date 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
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
1,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)
1,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 �—
Date:
Owner or authorized agent:
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
v
GENERAL PERMIT APPLICATION o MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION oho
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 ^ � misc
CUPERTINO (408)777-3228•FAX(408)777-3333•building0cupertino.org 1�I
LUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 5/R g s \v`� �� APN# 113 (� 3.5_ ^ 0 2- /
OWNER NAME -70 a Y\ ` — l P _ jIE j w_ EMAIL
STREET ADDRESS O 1 1 -'U Cf�Y,STATE,Z; FAX 6 1 FAX
CONTACT NAME-7 "'\
M WPHO l`i`-' S�CQS� I �JUL {V✓n (.. _ �.� (YtGGC
STREETADD SS �20
c�C AT�2; ^ 1SZ
FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME-,— �- ICENSE NUMBER LO71 1 LICENSE T�E BUS.LIC#
COMPANY NAMEAIL FAX
Q\_U vh ki k v1
STREET ADDRESS` �u E Z12 - ^ HONE f
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF or DUPLEX ❑ MULTI-FAMB.Y PROJECT IN WB.DLAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK / 1 0 , 4 a:4 v7 / f _ 6
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner'Aeha1LPKave read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. la c with all applicable local
ordinances and state laws relating to building construction. uthorize representatives of Cupertino to enter the above-id nti property for inspection purposes.
Signature of Applicant/Agent: Date: (3
SUPPLEMENTAL INFORMATION REQUIRED ' Ott
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r
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 5923 BOLLINGER RD DATE: 09/05/2013 REVIEWED BY: MELISSA
APN: 375 35 021 BP#: "VALUATION: $2,100
%PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY SFD or Du lex PENTAMATION 1 RPWS
USE: p PERMIT TYPE:
WORK REPLACE E MAIN WATER LINE FROM FOUNDATION TO PROPERTY LINE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1BPWSVCS 1 # $24
TOTALS: $24 00 `
IN Mm M
Xfech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
;Meeh.Permit Fee: Plumb.Permit Fee: IPPERAffT Elec. Permit Tee:
Other,tleah.Insp. Other Plumb Insp. 0.0 hrs $47.00 01her Elec.Imp.
He& Insp.Fee: Plumb. Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le 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 Dept for addn I info,
FEE ITEMS (Fee Resolution 11-053 E . 7111121 FEE QTY/FEE MISC ITEMS
Plan Check 14'ee:
Suppl. .PC I�ee
PME Plan Check: $0.00
Permit face:
Suppl. fnsf)I'ee
PME Unit Fee: $24.00
PME Permit Fee: $47.00
Construciion Tax
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning h7ees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$163 $163.50
x� $163.50 $0.00
Revised: 07/01/2013