13110113 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10480 JOHNSON AVE CONTRACTOR:SOUTHBAY PLUMBING PERMIT NO:13110113
OWNER'S NAME: PAM CAMPAGNA. 1659 N CAPITOL AVE STE 121 DATE ISSUED:11/18/2013
OWNER'S PHONE: 6052075904 SAN JOSE,CA 95132 PHONE NO:(408)613-5570
El LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE]
License Class C-3�Q Lic.# �O /3 PROPERTY LINE CLEAN OUT
Contractor TGmm :, Date
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.
t I hereby affirm under penalty of perjury one of the following two declarations: bAN
1 I have and will maintain a certificate of consent to self-insure for Worker's tid
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:$4000
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:37526042.00 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 WITHIN80 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 OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino.against liabilities,judgments, p
costs,and expenses which may accrue against said'City in consequence of the Issued by: Date: 1 0<
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. �_
RE-ROOFS:
Si natura_ < Date All roofs shall be inspected prior to any roofing material being installed.If roof is
g :;
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)
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 Diitrict 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 534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:��—�� 1� 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 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 APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 0
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MIS
GUi�ERTINO (408)777-3228•FAX(408)777-3333•building a.cupertino.org \r�
M/PLUMBING ❑MECHANICAL ❑ELECTRICAL [-]MISCELLANEOUS
PROJECT ADDRESS . `'(�O O V,A0Vx APN#��( J
OWNER NAME l�J�fi,ACJPHON O 2 _ �D,n E-MAIL
STREET ADDRESS W` CITY, STATTE,2�g �( �� FAX
�LJ �' c v«
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR N r LICENSENUr LICENSk PE BUS.LIC#
bWt vu �vt
COMPANY NAME E-MAIL FAX
STREET ADDRESS /' _I Z, CITY,STATE,ZIP 1r I PTO
L 1-3
,_55 70
ARCHITECT/ENGINEER NAME - - LICENSE NUMBER. BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 9SFD 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 WORKTN
Q Vvl D-:JVqdCgA,MP\ O C (J� I W I U
fY-,,ev,c-I, I-ens �4a cA
WIN iffim
•,
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the properly owner or authorized agent to act o th roperty 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 a ate. I agree to comply with all applicable local
ordinances and state laws relating to bui gz0[II r1`ucti n auth 'ze representatives of Cupertino to enter th ove-identified property for inspection purposes.
Signature of Applicant/Agent: L Date:
:a -
SUPPLEMENTAL INFORMATION REQUIREDp. oc
EXP.RES� .
MEPMiscApp_2011.doc revised 06/21/11
}
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: DATE: 11/18/2013 REVIEWED BY: Mendez
APN: BP#: "VALUATION: 1$4,000
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPSS
USE: p PERMIT TYPE: i
WORK � ro ertv line cleanout
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary1 PRSEWER 1 # $24
TOTALS: $24.00{} k..
011011 0
/ech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Llech.Permit Fee: Plumb.Permit Fee: IPPERMIT Elec:. Permil Fee:
FI,'
;llech.Insp. Other Plumb Insp. 0.0 hrs $47.00 Ocher Elcc.Ins}.
. Insp.Fee: Plumb. hap.Fee: Elec.Insp. (czc:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1113) FEE QTY/FEE MISC ITEMS
Plein Check Fee:
;5upj)1. .PCTee
PME Plan Check: $0.00
Perinit.F'ee:
Supp/. Insp Fee:
PME Unit Fee: $24.00
PME Permit Fee: $47.00
Cons•tr action Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes (E) No $0.00
Advtuwcecl Planning Dees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldy Stds Commission Fee: 1BCBSC $1.00
r
_ fn T .. E163$163.50 50$ 0
Revised: 10/01/2013