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14030085 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22863 LONGDOWN RD CONTRACTOR:CONSOLIDATED PERMIT NO: 14030085 PLUMBING INC OWNER'S NAME: NATHAN AND DIANE LEON 3732 CHARTER PARK DR STE D DATE ISSUED:03/13/2014 OWNER'S PHONE: 4082572660 SAN JOSE,CA 95136 PHONE NO:(408)978-3093 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL 2/, £�� REPAIR AND REPLACE(E)SEWER LINE,INSTALL(N) License Class J� # �J PROPERTY LINE CLEANOUT Contr r Date e affirm icensed under the provisions of Ch pter 9 (commencing with Section 7000)of Division 3 of the Business&Professions A Code and that my license is in full force and effect I hereby affirm under penalty of perjury one of the following two declarations: S 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:$17500 J)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:34233057 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 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 SPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the 3 3 granting of this permit. Additionally,the a Ii ant understands and will comply Iss Date: with all non-point regL a Cupertino Municipal Code,Section 9 18. " - OOFS: Sig f re DatAll roofs shall be inspected prior to any roofing material being installed.If a roof is Date 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 Munici al Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code ons ,2 ,a� 34. Section 3700 of the Labor Code,for the performance of the work for which this Owner or ant agen 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 Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY 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(See.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 O 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408) 777-3228•FAX(408)777-3333•building 8cupertino.org MISC CuVMkTINO P!jyLUNM]NG ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS d I I APN# 3 Lt Z - 3 .3 - o53OWNER NAMEQ© PHO d 7- STREET ADDREs! OC D EMAIL STREET ADDRESS ^ „ `C / CITY,STATE,ZIP.. FAX rJ� I CONTACT NAME V J PHO 22- STREET c r^ STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER '❑ O)xNm-BUIIAER ❑ OWNERAGEA? ❑ COIMZACTOR ❑CONTR,ACTORAGEAT ❑ ARCj-=cT ❑EN&INEER ❑ DENTLOPER ❑ TENANT CONTRACTORN LICENSENUMBER'I^5/6 Ll LICENS,T-E BUS.LIC# &UCK COMPANY NAMEV/J 5 0/l Q!t V E-' A' r F +7 STREET ADDRESS`73 Z:. CITY,STATE ZIP -� PHOh ARCHITECT/ENGINEE((RNAME LICENSE NUMBER BUS.LIC J COMPANYIN'A IE E-MAILFAX STREET ADDRESS CrTY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIDLAND ❑ YES T��D.O- CT AT ❑YES 7.,CF= THE BLDG AN ❑YES BUILDING: ❑COM[v1ERCIAL URBAN 1N=ACE AREA ❑ NO ❑NO HOME? ❑ NO DESCRIPTION OF WORK ✓/ TOTAL VALUATION: 7D, D _ By my signature below,I certify to each of the following: I am the-property owner or authorized agent to act on the property ovmer's be a . I have read this application and the information I have pr correct. ave d the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state la-,As relating to ilding c truc n. I o' epresentatives of Cupertino to enter the above-* e� r erty for inspection purposes. Signature of Applicant/Agent:01 Date: EMENT TFORMATION REQUIFtBD ;oF CE3Js>ah g� � a s� -v�� XPItESS �H� �` 314AJ , MEPMisct4pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION 7ADDRESS: 22863 LONGDOWN RD DATE: 03/13/2014 REVIEWED BY: MELISSA 34233057 BP#: *VALUATION: $17,500 OPERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Du lex PENTAMATION 1 RPSS USE: p PERMIT TYPE: WORK REPAIR AND REPLACE E SEWER LINE INSTALL N PROPERTY LINE CLEANOUT SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $24 TOTALS: $24.00 =1(rr. F';'urr t ru,� Plumb.Plan Check0.0 hrs $0.00 -rr�= �' P>rmid Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. 0.0 hrs $47.00 f x r:. Mn o. t'-:c:: phwlh. lnlv). NOTE: This estimate does not include fees due to other Departments(Le.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 Eff. 711113) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $24.00 PME Permit Fee: $47.00 �,`c�aa:}tftrzrio�� l�f.t: Administrative Fee: IADMIN $44.00 Work Without Permit? 0 Yes 0 No $0.00 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 $164.75 $0.00 TONAL FEE: Revised: 01/15/2014