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13100207 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1148 DERBYSHIRE DRCOT CTOR: („V Pj PERMIT NO: 13100207 Z DATE ISSUED: 10/30/2013 OWNER'S NAME: BECK RUSSELL E PHONE NO: OWNER'S PHONE: 4082523437 ❑ LICENSED CONTRACTOR'S DECLpARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL Cj'7lD Lic.#! 2� D PROPERTY LINE CLEANOUT License Class A Contractor�I- 1`I'-�Z�<<-� Dat.—Mb-40/11— I ate M�O 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. IT I hereby affirm under penalty of perjury one of the following two declarations: y1 I Tiave 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: a nation: 0 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:36221024.00 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 DAYS O IT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter INSPECTION. upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS F A indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Is y Date: 40/-$6 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. 1) RE-ROOFS: Signature "D "C 1, l_��(�� Date 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 Date: Signature of Applicant: 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) HAZARDOUS MATERIALS DISCLOSURE I,as owner of the property,am exclusively contracting with licensed contractors to 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 the Health&Safety Codetions 25505,25533,and 25534. 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 Owner or authorized agent: Date:lU 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 GENERAL PERMIT APPLICATIONv MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �\ MISC CUPERTINO (408)777-3228• FAX(408)777-3333•building aQcupertino.org PLUMBING MECHANICAL [—]ELECTRICAL MISCELLANEOUS PROJECT ADDRESS , t�y /�I&N(/ �I�G APN# 2— Z( 0 �U OWNERNAME t S`;'V L_ PHONE dg Z,5Z_ �2-7 E-MAIL STREET ADDRESS �1 r�'1% 'Dj (qZq�14 jq C�–�() CI NE ZI I CA � 7 FAX CONTACT NAME ``` C�1f–F7 r, F� PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CON17AVO NAME LIC EN ;MBF t� LIC tJil 'SPE BUS.LIC# GSA CONY N L - AIL J I Ii�A i I�T� FAX STREET AD SS CITY STATE,Z[P P ONE 6� ��eo�( CA 95 os 971- 30 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL F STREET ADDRESS CITY,STATE,Z[ P ONE USE OF W FD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA PjfNO FLOOD ZONE P_NO EICHLER HOME? ,`ER-NO DESCRIPTION OF WORK RnYi� TOTAL VALUATION: * 2C) By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the owne' 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 b construction. I auth ize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: a Date: J 70111.-3 SUPPLEMENTAL INFORMATION REQUIRED �pFFICEITSONLY �" c i. MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 1148 DERBYSHIRE DR DATE: 10/30/2013 REVIEWED BY: MELISSA APN: 362 21 024BP#: `VALUATION: $2,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PENTAMATION 1 RPSS PRIMARY SFD or Duplex PERMIT TYPE: USE: WORK PROPERTY LINE CLEANOUT SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $24 TOTALS: $24.00 A-f,(h, Plan Uhci k Plumb.Plan Check 0.0 hrs $0.00 P/af)Check r7�>Pf„rt 1��>, Plumb.Permit Fee: IPPERMIT 1:IEc- Pf,�rrir I e Orh = t'Ic� . Itis, Other Plumb Insp. E hrs $47.00 (J��rt f ta��c_Imp, Ey t lex h.Insp. l`x' 1'iurxh. LFsp. I,., l;iec 111sp. I'CC' NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the preliminaryinformation available and are only an estimate Contact the Dept or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff 711/131 FEE QTY/FEE MISC ITEMS Plan Check Fees: Si ppl. PC FCC, PME Plan Check: $0.00 Permit Frye: suppl. Msp F,lc PME Unit Fee: $24.00 PME Permit Fee: $47.00 Onstrtwfio 7 Tax: Administrative Fee: IADNIIN $44.00 Work Without Permit? 0 Yes Q No $0.00 ,1dti'OHO'd Phllmirw FCCS. Travel Documentation Fee: ITRA VDOC $47.00 A .Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item B1djz Stds Commission Fee: 1BCBSC $1.00 --T7=SUBTOTALS- $163.50 $0.00 TO'TALFEE $163.50 Revised: 10/01/2013