14040120 CITY OF CUPERTINO BUILDING PERMIT/
BUILDING ADDRESS: 10414 S FOOTHILL BLVD CONTRACTOR; C.,T PERMIT NO: 14040120
L
OWNER'S NAME: KENNETH M LEE DATE ISSUED:04/18/2014
PHONE NO:
OWNER'S PHONE:
JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
❑ LICENSED CONTRACTOR'S DECLARATION REPLACE MAIN WATER LINE WITH V COPPER/PVC
License Class ^3 p Lic.# q <3_5
Contractor�1 -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:$2500
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:35703072.00 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 O IT 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 F AST LED 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 Issue
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulat' er the Cupertino Municipal Code,Section
9 18.
rr -ROOFS:
Signature Date L All roofs shall be inspected pri any roofing material being installed.If a roof is
installed without first obtainin an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION Date:
Signature of Applicant:
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' 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)
1,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 Cupertin -ode,Chapter 9.12 and
Health&Safety ty Code,Sections 2 ,2 n
I have and will maintain Worker's Compensation Insurance,as provided for by the
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: 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 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.)
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 APPLICAT{ONE P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O�
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O�
(408) 777-3228•FAX(408)777-3333•building(a�cupertino.org MISC
CUPEE'T'IN0
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STREET ADDRESSCITY,STATE,ZIP FAX
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❑OWNER ❑ O,�iTNER-BUIIAER OWNER AGENT IrcoNTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANr
CONTRACTORLICENSB11,jR LICENSE E ^ BUS.LIC#
NAME
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COMPANY NAMEE-MAIL FAX
STRW ADDRESS CITY,STATE,ZIP PHONE
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COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF %PSFD or DUPLEX [3MULTI-FAMILYPROJECT IN WBALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: F1 COMMERCIAL URBAN INTERFACE AREA O FLOOD IONS -,.Q-NO EICHLER HOME? ja-NO -
DESCRIPTION OF WORK +t t -76-:YL—
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TOTAL VALUATION: RECE x v
0111-06.a_of w. IM
By my signature below,I certify to each of the following: I am the property owner or authorized a t to act on t perty owne' ehalf ve read this
application and the information I have provided is correct. ve read the Description of Work and verify it is accurate. I a to c with all applicable local
ordinances and state laws relating to buildin sentatives of Cupertino to enter the abov-ide ' property for inspection purposes.
Signature of Applicant/Agent: Date: 1
kUPPLEMENI!AL NATION REQUIRED
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STANDARD �
MEPMiscApp_201 Ldoc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10414 S FOOTHILL BLVD DATE: 04/18/2014 REVIEWED BY: MELISSA
APN: 357 03 072 BP#: "VALUATION: 1$2,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION 1 RPWS
USE: SFD or Duplex PERMIT TYPE: i
WORK REPLACE MAIN WATER LINE WITH 1" COPPER/PVC
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1BPWSVCS 1 # $24
TOTALS: $24.00
d e
b,e0i, Plan C h,(k Plumb.Plan Check 0.0 hrs $0.00 1='iec 1' air Ch
1e1+_Ptr�uit l i>e: Plumb.Permit Fee: IPPERMIT Elex_
Other Plumb Insp. ETrs $47.00 01h�, t%< r"3zs,,,
t"Ie'cfp wu. I.:e' Phinih
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./or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711113) FEE QTY/FEE MISC ITEMS
Plan
PME Plan Check: $0.00
4u(pll� I11sp Pce
PME Unit Fee: $24.00
PME Permit Fee: $47.00
( 017`7}'Ztt'non ICI:;":
Administrative Fee: ]ADMIN $44.00
Work Without Permit? ® Yes (F) No $0.00
"0vo,rc(,ii 11i"01,011r is!1,1ees:
Travel Documentation Fee: 1 TRAVDOC $47.00 i
Strom?Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
s= �= 163.50 $0.00 TOTAL FEE: $163.50
A
Revised: 04/01/2014