14020011 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10177 CAMBERLEY LN CONTRACTOR:CONSOLIDATED PERMIT NO: 14020011
PLUMBING INC
OWNER'S NAME: MCCRARY DONALD E AND MARGARET 3732 CHARTER PARK DR STE D DATE ISSUED:02/04/2014
OWNER'S PHONE: 4089968497 SAN JOSE,CA 95136 PHONE NO:(408)978-3093
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG T_ ELECT F PLUMB F
License Class n r Lic.# 1-6 S/c 2r—MECH RESIDENTIAL COMMERCIAL
Contractor &tQk 7�4/--5 Date&(—//-/
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:EXCAVATE&REPAIR SANITARY SEWER LINE ON HOME
(commencing with Section 7000)of Division 3 of the Business&Professions OWNERS PROPERTY
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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1200
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:34242025.00 Occupancy Type:
APPLICANT CERTIFICATION
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 cons"cc tion,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 D RMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS F M LLED INSPECTION.
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. Issued by: Date:
Signature 6i% � �` `'�"� Date
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 Owne or authorized ant:
become subject to the Worker's Compensation provisions of the Labor Code,I must s 6O `�`"� Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9 18.
Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408) 777-3228•FAX(408)777-3333•building 5cuoertino.org MISC
GUp1tyk 1 N 0
®:PLUMBING []MECHANICAL ❑ELECTRICALMISCELLANEOUS
PROJECT ADDRESS/0/7 7 azA cla �2&� I APN# 2��z O
OWNERNAME PHONE,/ - 71 E-MAIL
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STREET ADDRESS CITY STATE,Z (1f) I FAX
CONTACT NAME PHONE E-Iv AIL
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STEET ADDRESS CITY,STATE, ZIP FAX
❑ OWNER. '❑ OWNER-BUILDER ❑ OAWER AGENT TRACTOR ❑CONI-RACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME / LICENSE NUMBER J-0�1�+ 2 LICENSE TYPE 3 / BUS.LIC N7 ' 9w
COMPANY NAME E-MAIL (� L— (� FAX
STREET ADDRESS CITY,STATE,Z V-30-3 H74
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CFI-Y,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT rN WII.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COM IERCIAL URBAN IhI=N W]ACE AREA ❑ NG FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK �•
TOTAL\ALUATIOI: RECEIEDBY h » � €
By my signature below,I certify to eac owing: am the rt) o er or authorized agent to act on the property o mer's beh . I have read this
application and the information v provided is c . I hav ad escription of Work and verify it is accurate. Tap mply with all applicable local
ordinances and state lase s r ting U i nstruction. ze represent a ives of Cupertino to enter the above-identified ropert),for inspection purposes.
Si--natureofApplic Agent: Date:
PLEAfENTAL IT ION REQUIRED 4FEFn .
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sm -MID-P.D
MEP.ViscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10177 camberley lane DATE: 02/04/2014 REVIEWED BY: larrys
APN: BP#: *VALUATION: 1$1,200
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION
USE: pPERMIT TYPE: 1 RPS
WORK excavate and repair sanitary sewer line on home owners property
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1 PRSEWER 1 # $24
TOTALS: 1 $24.00
Vol
34",, ;,t:,:'t Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: 1PPERMIT
Other Plumb Insp. 0.0 hrs $47.00 ;r:r
NOTE. This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the preliminar information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
sapl,r1. /nsp
F-T
PME Unit Fee: $24.00
PME Permit Fee: $47.00
p1'1y F
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes 0 No $0.00
Ott t..s;ts fry b %c't{iltitiM' r %'r'.',-
t
Travel Documentation Fee: ITRA VDOC $47.00
Strona Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$163.50 $0.00 TOTAL FEE:
�aIALS " $163.50
Revised: 01/15/2014