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14080044 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22445 CUPERTINO RD CONTRACTOR:TRIPLE A PLUMBING PERMIT NO: 14080044 SERVICES OWNER'S NAME: SUNNY VIEW MANOR PO BOX 5144 DATE ISSUED:08/07/2014 OWNER'S PHONE: 4084545655 SANTA CLARA,CA 95056 PHONE NO:(408)245-4940 X LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL !' g REPLACING UNDERGROUND MAIN PIPE IN PARKING License Class Lic.# 7 3g LOT Contractor Oek- Date I hereby affirm that I am licen ed 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:$9800 ave 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: Lp Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMI EXPIRES WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 80 DAYS O 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 O CALLED IJCTIO�N indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the �� Lgranting of this permit. Additionally a applicant understands and will comply Issued by: Date: all non-point source regu do per the Cupertino Municipal Code,Section �'� � RE-ROOFS: ature Date r 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 Cupertin9vognicipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio OS ,and 25 4. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:G'71K 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 7-1i COr-AMUNITY DEVELOPhliENT DEPAR I HENT- BUILDING DIVISION 10300 T ORRE AVENUE• CUPERTINO, CA 95014-3255 (408) �tJ��ftTfliQ 777-322-B•FAX(403)77 -3333 (a� buildin� cupe rano.ora. M I s �0 PLL`t�ihG ❑1SCJA2,ICAL ❑ELECTRICA.L \ �I;15C�LLAI��OUS PP.O� ADDR SS a ,02rrXIzi a �� I c�IT R f I S-- 130 lY ao�gO'vJN=1.li.�N^ 4/ 51 7,_cT ADDPMS 2 a I CI T Y, STAT"c,Zug 9,5—o/ I r CON?hCT NAIME I ?HO> �n I ]Jt- t �'f STR�-ii ADT�s:S CITY,STAT;,ZIP FA vGi 13 O M '❑ OWI r?,-B-uM-DMt 13 OV.IMA!r ❑ COT'iR.4QO?, OTiZt�CiORA T ❑ f3.C-i_CI ❑/iNGTL?. ❑ D=\ 0?�' ❑ M .,T CGT"i kCTORNANs ` �� I LiC 'SEIv �E I LICS 3il pTYP i� l0 I 5.L .�/J� L ,.) 41 (� J / l� CO?.�f�'1]y'�✓?� Cl",,-� I c-t✓e.II, I FAX —� S t -!ADDRESS ( .CI'i Y,ST a2 2Y3 ?SCI i`I / GIl wP,N?.W.'; I Lic-ENSE NTLIBER. I BUS.LIC' COIJ.PAhTY NAME I E NiSII I FAX STRa-T ADDR SS I CrN.STATF,ZIP I PHOI t USE OF ❑SED or DUPLEX ❑ VMILTI-FAXvMY I PROJECT L*I WII. L QM ❑ YES I PP.OJECT IA ❑YFS IS=--BLDG AN ❑1=S BUII.DP:G: p c0i✓J E?cL-kL IMBAN ITT�tFAC=ARA p No FLOOD zoT: ❑No EIG� soles? [3!d0 DESCP.IPTION Or'YORK Y-% In20: S t,,, ,1 1 , ,r, n ,oma - TOTP.L � R�-�*�t�,�2•f""-�� By my signst*e below,I cer-tify to each of the following: I u',e propery oti;•�er or au ho iz;d agent to act on ropery o.,'Ier�s behalf I have re =is application and the in o ration I ha LL rovided' correct I haute Teal the Desc;iptiOD of Workand ve ify it is accza tE a_ree t lnp L le local O:Qlilan�.eS 47d Stat.-.is\;�S relator LQ VL ding 4 )0r I. I authl o L..�. r�SP.ntal\des oJ.'Ci-p'.l tl•L'1�L�e.ILP.r Lrle//Gb��:-L�enLl'1�'d 107..1 L��fir LS?eCii0T.1 pL'rpOSeS. Sir:a�ireofApplica^,t/AQent: Date: Ti' �� 7'PLEI\ AL L'I'FORI\AnON REQTJ=-D 0-1 . 1✓FPIk 'sc1pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22445 cupertino rd I DATE: 08/07/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$9,800 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION USE: Commercial Building PERMIT TYPE: 1 CPS WORK replacinq underground main pipe in parking lot SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PCSEWER 1 # $25 TOTALS: $25.00 410101Plumb.Plan Check 0.0 hrs $0.00 , 'i"w "7e"' I'errnil Fee: Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff 711/13) FEE QTY/FEE MISC ITEMS Pion, t"'f7'L;':F'"' PC 1'c PME Plan Check: $0.00 PME Unit Fee: $25.00 PME Permit Fee: $48.00 Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITR,4VDOC $48.00 Strong Motion Fee: IBSEISMICO $2.74 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 - TOTALw LS $169.74 . . Revised: 07/10/2014