13100097 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11289 TERRA BELLA DR CONTRACTOR:DRAIN DOCTOR PERMIT NO:13100097
OWNER'S NAME: TOMPKINS KATHLEEN S AND JOHN E 480 ALDO AVE DATE ISSUED:10/14/2013
OWNER'S PHONE: 4082592773 SANTA CLARA,CA 95054 PHONE NO:(408)370-3082
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 1 COMMERCIAL
License Class3� REPLACE(E)SEWER LINE WITH(N)TRENCHLESS
SYSTEM,
Contractor lc. L rJ 9 ot#'1A/ Date /O -1`2" i3 INSTALL(N)CLEANOUT @ FOUNDATION&REPLACE(E)
I hereby affirm that I am licensed under the provisions of Chapter 9 CLEANOUT PROPERTY LINE
ANIM � Alk InV
(commencing with Section 7000)of Division 3 of the Business&Professions TA
Code and that my license is in full force and effect.
I hereby affirm,under penalty of perjury one of the following two declarations: l
x I
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:$11000
L.! 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:35625009.00 Occupancy Type:
SAN
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the aboveinformation 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
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LA LLED 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 Iss O -�
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.
��� / 7 RE-ROOFS:
Signature .2�1// Date !U—A -'� 7 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. 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(x)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 06
permit is issued. Owner or authorized agent: Date:
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
`1
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION L�
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 v
CUpI`RTINO (408)777-3228•FAX(408)777-3333•building a,cupertino.org �\ MISC
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS ,/Z ,r-er/� e 11 -.. � I APN# 2 (> ZJ � O O
OWNERNAME ro (ONS 2�r� 7 3 E-MAII
c1 �... ��+� " 8 J
STREET ADDRESSCITY,STATE,ZIP FAX
(rr4, r3e1k W —P eA gs oj`f
CONTACT NAME PHONE -/37 1 E-MAIL
STREET ADDRESS L} ^ e Z -3 CITY STATE,ZjP FAX
❑OWNER ❑ OWNER-BUII,DER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHrrECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME ` J O LICENSE NUM],f R��_ IfreETYPE L, BUS.LIC#
COMPAN;NAME ` o c- u (' �IrMAIL'S FAX
STREET ADDRESS T CITY,STATE ZIP PHONE
=c L e A v IC S' ,,i p- C1 190 I Z'I' -/1111
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAII FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WEALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
5 »ay
TOTAL VALUATION: 0 D M A
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pro erty owner' hal£ 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 t omply with all applicable local
ordinances and state laws relating to building nstyion. I authorize representatives of Cupertino to enter the above-identified prop e for inspection purposes.
Signature of Applicant/Agent:� Date:
SUPPLEMENTAL INFORMATION REQUIREDNNUMMOV— AVM
s�4:-..
P
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 11289 TERRA BELLA DR DATE: 10/14/2013 REVIEWED BY: MELISSA
APN: 356,25 009 BP#: *VALUATION: 1$11,000
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS
WORK REPLACE E. SEWER LINE WITH N TRENCHLESS SYSTEM INSTALL N CLEANOUT
SCOPE FOUNDATION & REPLACE (E)CLEANOUT @ PROPERTY LINE
APPLIANCE/EQUIP TYPE !FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $24
TOTALS: y $24.00
Me& Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec..Plan Check
Fech.Permit Fee: Plumb.Permit Fee: 1PPERMIT Elec. Permit tee:
Other;Meeh.hu1>. Other Plumb Insp. 0.0 hrs $47.00 Other GleeImp.
Wech.Insp. Fee: Plumb. Insp.Fee: Elec.Insp,Fee:
NOTE:This estimate does not include fees due to other Departments(L a Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 Eff.' 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Stipp/. PC'Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $24.00
PME Permit Fee: $47.00
C onswuction :1'a :
Administrative Fee: 1ADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
A dvunced Planning Feet:
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $1.10 Select an Administrative Item
Bldg-Stds Commission Fee: 1BCBSC $1.00
$164.10 $0.00 � `ta TOIL FEE $164.10
+ p fry
Revised: 10/01/2013