14050061 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 922 MILLER AVE CONTRACTOR:TATS INC DBA MR PERMIT NO: 14050061
ROOTER PLUMBING
OWNER'S NAME: BAYS CARMEN L TRUSTEE 1260 YARD CT DATE ISSUED:05/08/2014
OWNER'S PHONE: 7144696610 SAN JOSE,CA 95133 PHONE NO:(408)271-2822
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
k REPLACE SEWER LINE&PROPERTY LINE CLEAN OUT
License Class ( I Li'c.#_367-61_5
Contractor m ,2Uw 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:$6900
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:37541010.922 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 DA F 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 FR ALLED INSPEYTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: 0 Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
r RE-ROOFS:
Signature L�/.C1�ti. �(� DateAll 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)
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 Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent:
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(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 MEP
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COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �O
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 M AM ISC
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eu4%A-rtNo (408) 777-3228•FAX(408)777-3333•buildina(cDcuDertinO.org V�
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[PLUMBING [:]MEMANICAL ❑ELECTRICAL �{❑MIS CELLLAANEODU/Sn
PROJECT ADDRESS q J �N#
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STREETADDRESS3�S I, le� I C Aer / q� I F
CONTACT NA HO iG I' PHO C� �� E-MSII.
STREET ADDRESS CITY,STATE,ZIP I FAX
❑ OWNER ❑ wwxT R-BuLDER ❑ ommaAGEN-r CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENG1NEER ❑ DEVELOPER ❑TENA,7
CONTRACTOR NAMELICENSE NUMIBER LICENSE TYPE BUS.LIC#
6t 1' C" S I I L
COMPANY NAME E-MAIL FAX
STREET ADDRESS CTTY,STATE,ZIP I PHON
ARCHITECT/ENGINEER NAME LICENSE NUMBER. BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI•FAM LY PROJECT IN WU DLAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN El YES
BUILDING: E]COMMERCIAL I URBAN INTERFACE AREA NO FLOOD ZONE /l NO EICHLER HOME? l-'O
DESCRIPTION OF WORK
A 7
TOTAL VALUATION:
By my signature below,I certify o each of the following: I am the property ovmer or authorized agent to act on the prope Owner's bA alf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. _ ply wdth all applicable local
ordinances and state laws relating to g construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL D\TFO1?-1,6A REQUIRED
Q
... T _
CRESS
MEPMfsct4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 922 miller ave DATE: 05/08/2014 REVIEWED BY: Mendez
APN: BP#: *VALUATION: 1$6,900
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS
WORK re lace sewer line & property line clean out
SCOPE
WecTt_ W(m€'h,,k Plumb.Plan Check 0.0 hrs $0.00 F/eu. Pian
"&,c/t. Fee: Plumb.Permit Fee: IPPERMIT
C)i/t�rrei'i. IrFs°/=. Other Plumb Insp. 0.0 hrs $47.00 t)z/ter t>t'cc.l rte.
Phan/. h;SP. /'{'g; /,f.'(•./t?St) 1' r2:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These _f
fiees are based on the relimina information available and are onlyan estimate. Contact the Detor addn'l info,
FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Plumbing
Suppl. PC Fee: Q) Reg. 0 OT Q,Q hrs $0.00 $24.00 IPRSEWER Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee.0 Reg. ® OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes C) No $0.00 G
Advanced Plannint Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: 1TRAVDOC $47.00 Building or Structure 0
Strong Motion Fee: IBSEISMICR $0.69 Select an Administrative Item
Bldg;Stds Commission Fee: 1BCBSC $1.00
pr L $139.69 $24.00 TOTAL FEE: $163.69
Revised: 04/01/2014