13100148 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10171 SANTA CLARA AVE CONTRACTOR:GREAT AMERICAN PERMIT NO:13100148
PLUMBING CO INC
OWNER'S NAME: BOOTH ROBERT K AND RANA M P O BOX 26942 DATE ISSUED: 10/23/2013
OWNER'S PHONE: 4082570737 SAN JOSE,CA 95159 PHONE NO:(408)279-1515
VX LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class C Lic. PROPERTY LINE CLEAN OUT
Contractor�e21`�f%41°✓l((*P61tiDate L6-
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.
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:$4589
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:32624047.10171 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 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 RO LAST 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 Date: / ?
granting of this.permit. Additionally,the applicant understands and will comply Issued by:
with all non-joint source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Sign to 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
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 witha Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' ns 25 5, 5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized age Date: d 3'
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.)
Lenders 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 q MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION b�
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTlNO (408)777-3228•FAX(408)777-3333•buildind(a.cupertino.org s misc
PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS `1 I 54y-M C4AI64- 10 APN#
OWNER NAME f` tJu n PHONE C-� m
3 E-MAIL
r�
STREET ADDRESS CITY,STATE,ZIP C Ll n;/ly A FAX
CONTACT NAME PHONE E-MAIL,.,
STREET ADDRESS C, CITE,STATEIP [ S FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME �L LICENSE NUMBER s LIC04SE�E BUS.LIC# �D /
r �-
COMPANY NAME EMAIL FAX
9q M',;27c 13
STREET ADDRESS/ 6 4-144
®49AW A 1( CT S TATE oD � C PHON 0 n_,-)7C`/S
ARCHITECT/ENGINEER.NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUI1DING ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK �� L
_7 �A
vv_\
I i
TOTAL VALUATION: Leo
a .�
By my signature below,I certify toe ch of the following: I am the property owner or authorized agent to act on the roperty owner's behalf. I have read this
application and the information I ha provided is correct. I have read the Description of Work and verify it is ac ate. I agree to comply with all applicable local
ordinances and state laws relating to uilding cos tion. aut presantatives of Cupertino to enter the aabovee identified pro erty for inspection purposes.
Signature ofApplicant/Agent: Date: / (ti
PL MENTAL INFORMATION REQUIRED
�.a ,g EXPRESS
9 3:
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10171 SANTA CLARA AVE DATE: 10/23/2013 REVIEWED BY: MENDEZ
191APN: BP#: "VALUATION: 1$4,589
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPSS
USE: p PERMIT TYPE:
WORK PROPERTY LINE CLEAN OUT
SCOPE
e.....z^,.3
Xfec:li. Flan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.flan(,,heck
Afech. Pennif Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit lee:
r
11ech.Insp. Other Plumb Insp. 0.0hrs $47.00 Other`Elec.Insp.
EiLd
. Insp.Fee: Plumb. Insh. Fee: Elec.Insp,Fee:
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 prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7f /f 1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Plumbing
Suppl.PC Fee: E) Reg. ® OT 0.0 hrs $0.00 $24.00 1PRSEWER Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:Q Reg. ® OTo] hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Consiru(.1ion 7 ax:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes (j) No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential G
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure 0'A
Strove Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldu Stds Commission Fee: IBCBSC $1.00
$139.501 $24.00 � T % lii FLE $163.50
Revised: 10/01/2013