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14030084r CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22821 LONGDOWN RD CONTRACTOR: CONSOLIDATED PERMIT NO: 14030084 PLUMBING INC OWNER'S NAME: RAUSCH DORIS B 3732 CHARTER PARK DR STE D DATE ISSUED: 03/13/2014 OWNER'S PHONE: 4089963574 SAN JOSE, CA 95136 PHONE NO: (408)978 -3093 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL REPAIR AND REPLACE (E) SEWER LINE, INSTALL (N) License Cl Lic. # �= —1� 2-- ass PROPERTY LINE CLEANOUT Contracto Date) I her arm tha censed under the provisions of C pter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. AL I hereby affirm under penalty of perjury one of the following two declarations: tfi 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: $11500 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 34233051 00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this 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 FRO ED 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 sued Date: granting of this permit. Additionally, the a plicant understands and will comply with all non -point so la i pe Cupertino Municipal Code, Section 9 18. Si tur Date �W RE- ROOFS: 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 with the Cupertino Munic' al Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Se 5 , . 5534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner or authorize a Dater I certify that in the performance of the work for which this permit is issued, I shall OM� not employ any person in any manner so as to become subject to the Worker's ION 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 wc,2.is�s i n GENERAL PERMIT APPLICATION � MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(cDcuoertino.orq MISC I—'ItTI ITT11AT M- CT T.Z(-TVTr,AT- nMTSCELLANEOUS d=J- UIVlrsuvv u,�,L� PROJECT ADDRESS APN # OWI.TERNAME �� PH7(l '� / 7�0 •� ��/ B -N•AII, STREET ADDRESS �RA CTTY, STATE, Zip .. I FAX CONTACT NAME n E M PHONE � STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER -❑ OWNER- BUILDER ❑ ON'ATER//AGENT ❑ CoNMUCfOR ❑CONTTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME xG x LICENSENUNIB ®`+ n ` LICENSE TYPE ^� BUS. LIC# COMPANY NAME n E-MAIL �CC FAX �� y f /v / STREET ADDRESS i CITY. S TE� /�f� PH ARCHMMENGDMER 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 WIALAND ❑ YES T�:DZONE ECT IN ❑ YES IS THE BLDG AN ❑ YES " ❑ BUILDING: ❑ COMMERCIAL IMBAN D TERFACE AREA ❑ NO ❑ NO EICHLER HOME? NO DESCRIPTION OF WORK A l 6'-'e 201 M 10 ..c4qLk4L Saw 100 -05 som TOTAL VALUATION: -� By my signature below, I certify 'd each of th I am th owner or authorized agen act on the e ehalf. I have d this 'able application and the information I have vlded is.corre . I e read escription of Work and verify it is accur2 te. to comply with all applic local ordinances and state laws relating t ilding cons io I auth repres ntatives of Cupertino to enter the above- identified pro /perry for inspection purposes. Signature of Applicant/Agent: Date: P NTAL ATION REQUU2ED O � s bn r ; �' �t- ®AS'ERTE�COIIit�R��` 1 NOR ��XPRESS�� .W ` �Te�'DA'RD� - - `I13A TU — MEPMisc,4pp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION im, ADDRESS: 22821 LONGDOWN RD FEE DATE: 03/13/2014 REVIEWED BY: MELISSA APN: 342 33051 BP #: � EVALUATION: 1$17,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex PME Plan Check: $0.00 PENTAMATION PERMIT TYPE: 1 RPS WORK REPAIR AND REPLACE E SEWER LINE INSTALL N PROPERTY LINE CLEANOUT SCOPE erk I I Plumb. Plan Check 10.0 1 hrs $0.00 1,kc. 1' n 'hecl Fec(r_ t'emiit I ef.>.. Plumb. Permit Fee: 1PPERMIT f � �. Fs:rar f Fee: odr (r ;U,c b? fnsr, Other Plumb Insp. 0.0 hrs $47.00 01l7er° h ,,jn {'Ax' . Insp. I , r 1'lunitr. drib /). Fee. 1 ;bec . ! 3„ 1 v,., NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Tb;of.;nt ofn 1 Th— foo o h—d na 1ha nro/iv ;—, ;"fors "dnn miailahla and aro nnk an ovtimata Cantart the Dent for addn'l info_ FEE ITEMS (Fee Resolution 11 -053 Ef. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: � Sarppl. PC e'e PME Plan Check: $0.00 111:%/) Fee PME Unit Fee: $24.00 PME Permit Fee: $47.00 Administrative Fee: 1ADM7N $44.00 Work Without Permit? 0 Yes 0 No $0.00 ,1 ; /VYW,','fA1 /M'1atr'rig Fees: Travel Documentation Fee: 1TRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $1.75 Select an Administrative Item Bldg, Stds Commission Fee: 1BCBSC $1.00 $164.75 $0.00 k TOTAL FEE= $164.75 Revised: 01/15/2014 r Address SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building aacugertino.org PURPOSE This affidavit is a self - certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single- family and multi- family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and /or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) X X On every level of a dwelling unit including basements X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel- burning appliances and that do not have'an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above - referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below. 1 have read and agree to comoly with the tem7s and conditions of this statement Owner (or Owner AgenfssJJ) Name: pp 2 - Q viti�S /C/ur Cam, Si nature. .... :....... ................ .......................... Date: kV, ....1.... . C C Li c.# .... Date: .7.... . Smoke and CO form.doc revised 03118114