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14090169CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10775 WILLOWBROOK WAY CONTRACTOR: MARTI'S PLUMBING PERMIT NO: 14090169 OWNER'S NAME: HERNANDEZ MATHEW R AND LISA B 10260 IMPERIAL AVE DATE ISSUED: 09/25/2014 OWNER'S PHONE: 4084998132 CUPERTINO, CA 95014 PHONE NO: (408) 375-3190 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL REPLACE SEWER LINE (SUNNYVALE JURISDICTION) License Class Lie. # 7-0 ff"- r Contractor T ` S MfmL Date 1-26-- (41 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 Sq. Ft Floor Area: Valuation: $7300 performance of the work for which this permit is issued. 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: 36922036.00 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 1 ERMIT 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 OM 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 -q1z511q granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9 18. c� 0 ROOFS: Date Signature � any r All roofs shall be inspected prior to y 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 Cupertino Municipal Code, Chapter 9.12 and 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 the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Dater 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 PIsRMIT APPLICATION (� k.. ...` COIVNUNI TY DEVELOPMENT DEPART MENIT - BUILDING DMS Iti 10300 T ORRE AVENUE - CUPERTINO, CA 95014-3253 U, (40B) 7777-32A FPX (403) 777-3333 - building.Q.moerMno.ora U� I s G IV -.Cti.=11iCAL PROi�f.DDRSS � I V� I "J l/"1 �IG.I�hvMilL II�A.�I I L'T' 03(0 ll &Z i I '104 40% - 1Jl3 I J4L ; J CONTACT KA -I G ( I i0 \r✓ I = 1J �I✓ S-11 1 ADDRESSe,C (f La ORt ❑ OSI -BL�� !] 071.' ACD.? ❑ CO? 4C OR ❑mmu,CTO&AGki ❑ f.P�__CT ❑ G�'_ : ❑ D— 0?=e ❑ -�i'Z COh:?kC?ORI�AI.�' �G1/�, I LiC.-�.TSfil�ZTl� � � � I �C 'cil� E � 3US.LICr i0-2C, COW2AM,N.i1.r' . �v1 C =�Jdb I p8 ^-1' ADD?'eg S 1Sc1i �2 � J' I CI1 Y, STATE, ZIP I t � P?OIC ri Hod., 37s-6 P�c?u:SCT/E GIhut I��1JJ I LiCTSENUA�i I BUS. LIC r COWAIQY 1QAJa I sil✓ia II. I FAX STR ossT ADDR SS I CITY, STAit ZIP I PiiOh� VSn Or, ❑ -sm or DI PLEX mm-n7Abffi.Y I MOM CT N WII.DLA-NM ❑ YES BT-j=*IG:❑CO1n_P.CmL 13RBANDIIM—RrA=j62SA NO I PROJECT A ❑ YES mom?ow- ( TO � IS TT BLDG M ❑ Y'=S FiCE,=- HOME? M„`.>\O DESCP.IPTION OF WORK �} • UC.,•Q. IGC; (l �'� 1r1Cy� Il 1 OTF T \: a T UA11ON: V Q pC1 was. r L��* 'T '. - •.T .- �., ' �`_. "'yr 4.. _ By my sig atare holo;+, I ce to each Of the follo;;� ,g I am the property oamer or authorized €gent t0 act oil the pro mmner s behalf. I have read this r Pe "y applimtion and the informadon I have provided is cored I have read the Desi ipdon of gork and veary it s zccT ate. I ag ee to comply'Aith all applicable local ordffimices and =te ia;Vs relatLlg top 'ldine corsvcdcn. I authorze r epr-sentatives of Cope; :ino `o eater the pbbove-id-d proper`:�� for i^ ec ion poses. Ohl -SIS �leor._y tLV z�enG-190�1attt: -'2 SU-PPTEI;NTALrORh�i�TI U)D Q ON • � --"P _ =cE�I.;�_— _- � _a __ aYt 'v'i IXC,-` -�. 1F ?.Aosc., /pp 201.7.doc revised 06121111 CITY OF CUPERTINO WN FEE. ESTIMATOR - BUILDING DIVISION ADDRESS: 10775 willowbrook way DATE: 09/25/2014 REVIEWED BY: Mendez APN: BP#: -VALUATION: 1$7,300 *PERMIT TYPE: Building Permit $0.00 PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex PENTAMATION PERMIT TYPE: 1 RPS WORKre lace sewer line $0.00 SCOPE $0.00 btu I': air t_ rt L Plumb. Plan Check 10.0 1 hrs $0.00i ='e�' Pr>tratri Fee: Plumb. Permit Fee: IPPERMIT t„eco 1'E<rtr+z` 0,F.r?, ;l -Itch, I.rs;, Other Plumb Insp. 1 0.0 1 hrs 1 $48. 001 oiyl er i irec, Inasjr. it cia. fn_sp. I r: I f1u2 nb Ins)), 7"ee: I Iat=c.lri NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School nictript oto ) Thom foot aro hhcod nn tho nroliminam infarmadnn availahlo and aro nnly an o.wimato_ f'nntact the Dent for addn'l infn. FEE ITEMS (Fee Resolution 11-053 Eff. 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # $25.00 Plumbing 1PRSEWER Sewer, Sanitary Suppl. PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:(E) Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Flee: $48.00 _FT Administrative Fee: IADMIN $45.00 0 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select allon-Residential Building or Structure 0 i Travel Documentation Fee: ITRAVDOC $48.00 Strom Motion. Fee: IBSEISMICR $0.95 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 ;, N- $142. $142.95 TI— $25.00 -©TAL FEE: $167.95 Revised: 08/20/2014