14080211 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10470 PINEVILLE AVE CONTRACTOR:ABLE SEPTIC PERMIT NO: 14080211
OWNER'S NAME: GORGEN GARY A AND IRIS M TRUST P O BOX 24819 DATE ISSUED:08/20/2014
OWNER'S PHONE: 4082528659 SAN JOSE,CA 95154 PHONE NO:(408)377-9990
❑ LICENSED NSED CONTRAC OR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
�] REPLACE SEWER LINE WITH PROPERTY LINE
License Class Lie.# `� CLEANOUT.
Contractor Date
I hereby affirm ha 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:$4600
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:36913035 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 FROM LAST CALLED 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 ,gi� �G -aU 7
granting of this permit. Additionally,the applicant understands and will comply Issued by:;/ r r Date: I
with all non-point source gulations per the Cupertino Municipal ode, ection
9 18.
RE-ROOFS:
S i g n a t u r Dat U" 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 Cup Ino Municipal Code,Chapter
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,ZACtii5,25533,and 25534. n
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent. Date d /
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
CONSTRUCTION PERMIT APPLICATION
13 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building[cuoertino.ora
❑NEW CONSTRUCTION ❑-ADDITION ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 7PT-- APN JVV #�� !
OWNERNAME • P E-1M9II•
r 1 '?�2
STREET ADDRE S�� I ,JIL e CITY, STA C AX
CONTACT NAME V� PHONE E-MATL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME - LICENSE LIC BUS.LIC#
COMPANY NAME 1 E F
"I
STREET ADDRESS P �Q^.0 CITY, J AA
J s
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WO
Ite-W6 CAL --0A4La-r-- UM& eA� olzft
EXISTING USE PROPOSEDUSE CONST E #STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG!— NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA I DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑VES
BEING_41)DED? ONO ADDITION? ONO
PRE-APPLICATION OYES IF YES,PROVIDE COPY OF ISTHE BLDG AN ❑YES -RECEI BS'; TOT/A'LVALUATION:
PLANNING APDL# ❑NO PLANNING APPROVAL LETTER - EICHLER HOME? ❑NO / 00
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provideswis correct. I have read the Description of Work and verify it is a-- e. I agree to comply with all applicable local
ordinances and state laws relatin to b ' traction. I authorize representatives of Cupertino to enter the -identifi Pop for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL 1NITIOINkKTION REQUIRED PLAN CHEcrcTYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit forovER-TIcoIIN PERsulLDnvs;PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of buildtng f
permit for new building. D"EXPREss ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure :❑.STANDARD El PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. II 4ptc ❑ FDtE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. MnJOR. ❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTALHEALTA
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
W�PERMIT
DDRESS: 10470 Pineville Ave 1 ]DATE: 08/20/2014 REVIEWED BY: Sean
PN: BP#: -VALUATION: $4,600
PE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS
WORK �Re lace sewer line with property line cleanout.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $25
TOTALS: $25.00
,s
54111
'h!' "' ]'/art 0"ie-A Plumb.Plan Check 0.0 hrs $0.00 1°aec,1' '
""111:/1 Pere t;"1 Fee:: Plumb.Permit Fee: IPPERMIT f;irr- �err:rir tt�e.
:'.,� ec° . f ,�rt.
Other 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 Dept-for addn'l info.
FEE ITEMS (Fee Resolution 11-053 a.' 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check r*,W:
PME Plan Check: $0.00
sufopll Fe",
PME Unit Fee: $25.00
PME Permit Fee: $48.00
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
(CIt'c ztr's't
Planning /'t.TS:
Travel Documentation Fee: ITRAVDOC $48.00
Strong:Motion Fee: IBSEISMICR $0.60 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$167.60 $0.00 TOTAL FEE; $167.60
Revised: 07/10/2014