13100004 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7513 PEACH BLOSSOM DR CONTRACTOR:ULTIMATE CONCRETE PERMIT NO:13100004
CO
OWNER'S NAME: LING P LU 837 PALM ST DATE ISSUED: 10/01/2013
OWNER'S PHONE: 4087323567 SAN JOSE,CA 95110 PHONE NO:(408)295-6204
❑ LICENSED CONTRACTOR'S DECLARATTIO11
�N JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class_ Lic.# `7 REPLACE(E)SEWER LINE&INSTALL PROPERTY LINE
Contractor Date FOUNDATIONA T
4hy
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. ITANX
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:$2500
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:36611131.00 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 DAY 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 DAY S`T CALLED INSPECTION.
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 Date: /0
with all non-point ource regulatio s e Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signatur Date/o//v 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,
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 Cup lino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec'ons 2ZZ
534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: Q
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 cityand 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 �
o MEP
vi COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O
CUPEKTINO (408)777-3228•FAX(408)777-3333•building(@-cupertino.org MISC
[:1 PLUMBING EINECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS C , _ Q v, APN#
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CONTACT NAME PHONE E-MAIL
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T`QWNER ❑ OWNERBUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME�nh,� p LICENSE NUMBEjL�g& LICENSE TYP BUS.LIC#
COMPANY NAME E-MAIL FAX
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ARCHITECT/ENGINEER NAME LICENSE NUMBER l% ` / V BUS.LICCOMPANYNAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAmmy 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
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TOTAL VALUATION:
By my signature below,I certify toeach of the following: I am the property owner or authorized agent to a er'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 accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. authorize rep entatives of Cupertino to enter the above/-identif, property for inspection purposes.
Signature of Applicant/Agent: f Date: /
SUPPI61ENINFORMATION REQUIRED
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 7513 PEACH BLOSSOM DR DATE: 10/01/2013 REVIEWED BY: MELISSA
APN: 366 11 131 BP#: "VALUATION: 1$2,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
WORK REPLACE E SEWER LINE & INSTALL PROPERTY LINE & FOUNDATION CLEANOUTS
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $24
TOTALS: $24.00
OWNs
L1ech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 F_lec.Plan Check
:L1c>ch. Ternlit Fee: Plumb.Permit Fee: IPPERMIT Elec.Permit Fee:
CJilrc.-r:19e<h.Insp. Other Plumb Insp. 0.0 hrs $47.00 Uther Elec.Imp. Li
ldech. Imp. Fec: Plumb. hasp.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 ees are based on the preffinWha information available and are on an estimate Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 E . 711/13) FEE QTY/FEE MISC ITEMS
Plant Check Fee:
Supp 1. PC I'ee
PME Plan Check: $0.00
Pertnit Fee:
Suppl. 117sp Fee
PME Unit Fee: $24.00
PME Permit Fee: $47.00
Construction Tat:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes C) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
131da Stds Commission Fee: IBCBSC $1.00
$163.50 $0.00 $163.50
`l , Revised: 08/01/2013