14020074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22953 LONGDOWN RD CONTRACTOR:CONSOLIDATED PERMIT NO:14020074
PLUMBING INC
OWNER'S NAME: LOWDEN SYLVIA A AND TIMOTHY E 3732 CHARTER PARK DR STE D DATE ISSUED:02/12/2014
OWNER'S PHONE: 4083686394 SAN JOSE,CA 95136 PHONE NO:(408)978-3093
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
PROPERTY LINE CLEAN OUT
License Class Li,.# 2_
Contractor 7 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.
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:$15000
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:34240014 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 1 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 ROM L ST 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: a��a
granting of this permit. Additionally,the applicant understands and will comply Issued by:
with all non-point so a regulations er the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signatur Date 2/ 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
1,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 theTLENDING
' ' al Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ' n25534.
Section 3700 of the Labor Code,for the performance of the work for which this A
permit is issued. Owner or authorized entDate:2
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 CONSTRUCGENCY
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
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(408) 777-3228•FAX(408)777-3333•buildina(5cupertino.ora COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
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1
LUMBING ❑MECHAINrICAL ❑ELECTRICAL []MISCELLANEOUS
PROJECT ADDRESS q � APN#
OWNERNAME PHONE 1tMAII �y � �
STREET ADDRESS CITY, ATE,ZIP � I FAX
CONTACT NAME PHO E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWTIERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMELICENSE NUMBER LICINSE TYPE BUS.LIC#
COMP AME E-M
STREET ADDRESSCITY,STATE
PHONE
rS
So
ARCHITECT/ENGWEER 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 WII.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑TES
BUILDING: ❑COMMERCIAL URBAN IIdfERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK A1f
TOTAL VALUATION: w 3 -ELVEDBX
_ SR _a• �.
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property mGmer's behalf. I have read this
application and the information I ha, ed is. . I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relati o, ng ctio,4 authorize representatives of Cupertino to enter the above-identi ed roperty for inspection purposes.
SignatureofApplicantlAge Date:
.
S NTAL INFORMATION RE UIRED
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AIEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
W*PERMITTYPE:
DDRESS: 22953 longdown rd DATE: 02/12/2014 REVIEWED BY: Mendez
PN: BP#: *VALUATION: $15,000
Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: p PERMIT TYPE:
WORK ro erty line clean out
SCOPE
� � "
-. k� ss
lr'eh, PkV'i Plumb.Plan Check 0.0 hrs $0.00 �'ic'c. 1'hn Cnack
i•1e,rI !"'rim:I Fee: Plumb.Permit Fee: IPPERMIT Fc,
;•,, ��,: ,. „�,r. Other Plumb Insp. __1hrs $47.00 �ttrt:t 1�t<°c.tnsfl.
El
1fle",Ins{) Pcc,
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These
-fees are based on the prelhiniina information available and are only an estimate, Contact the Dept for addn'1 in o.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl.PC Fee: Q Reg. ® OT 0.0 hrs $0.00 $24.00 IPRSEWER Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes (F) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure ,
Strong Motion Fee: IBSEISMICR $1.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
yb
" ALS $140.50 $24.00 TOTAL FEE: $164.50
,
Revised: 01/15/2014