15010004 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20061 FOREST AVE CONTRACTOR:MIKE COUNSIL PERMIT NO: 15010004
PLUMBING INC
OWNER'S NAME:
SAN JOSE,CA 95131 PHONE NO:(408)272-4900
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E]
REPLACE(E)SEWER LINE FROM FOUNDATION TO
License Class C—'3 Lie.4 C11� p � �' � PROPERTY
Ke Co�J n��1 Qlvw%bcn�Date a I2�) LINE,INSTALL 2 CLEANOUTS&REPLACE 6' OF(E)
Contractor dH BUILDING DRAIN _
I hereby affirm that I am licensed under the provisions of Chapter 9 `"f
(commencingwith Section 7000 of Division 3 of the Business&Professions '%AN'1a '
Code and that my license is in full force and effect. T"' X?�
Ihereby affirm under penalty of perjury one of the following two declarations: bA
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:$31193
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:31633065 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 save180 DAYS F 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 Date: z
granting of this permit. Additionally,the applicant understands and will comply b3'
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date +I2 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
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,Sections 25505,25533,and 25534.
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
918.
Signature Date
GENERAL PERMIT APPLICATION 1: MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O\
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building0)cupertino.org MISC
CUPERTINt�
C�MUMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 6 0 I C r e s e APN#
OWNER NAME /
STREET ADDRESS CITY,STATE,ZIP / FAX
aoo� I Fore-5,v ,Av C��e t'k, �� 1 �/
CONTACT NAMEP ONE E-MAIL
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STREET ADDRESSTAT' � I 0 e m'E,j 05 Q 6 9 3-/ 3 1 FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT b CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
C pq ,:d� (ri
CONTRACTOR NAME LIc�ENSE NUMBER LICENSE TYPE BUS.LIC#
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COMPANY NAME l l
U FAX
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STREET ADDRESS 01 (DI 100'e C S STATE, IP PH
O y0 -Y72-910 0SDJC T SJ
ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS.LIC#
COMPANY NAME E-MAEL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES
BUILDING: ❑ �
COMMERCIAL URBAN INTERFACE AREA ®-NO FLOOD ZONE RINO EICHLER HOME? `NO
DESCRIPTION OF WORK
Sewer c)'i J
tc] � roPer� � 1 � � . Sewed v � � e � k0r -2.
SeC0�-JC' r s
TOTAL VALUATION: ( � 3
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prope alf. I have r
application and the information I have provided is corre ave read the Description of Work and verify it is accurate. I a e to comply with all applicable local
ordinances and state laws relating g cons on, autorize represe
hntatives of Cupertino to enter the abo a-i nntified property for inspection purposes.
Signature of ApplicanVAgent:`:, � Date: 2
6NL
SUPPLEMENTAL INFORMATION REQUIRED ?"y
OEELCE IJSE
"'WR-THE-CO OR 0"
�EXPR�SS
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STANDARD ,.;
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MAJOR x
MEPMiscApp_MLdoc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20061 FOREST AVE DATE: 01/02/2015 REVIEWED BY: MELISSA
APN: 316 33 065 BP#: 'EVALUATION: 1$31,193
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Du lex PENTAMATION 1 RPSS
USE: p PERMIT TYPE:
WORK REPLACE E SEWER LINE FROM FOUNDATION TO PROPERTY LINE INSTALL 2 CLEANOUTS &
SCOP I REPLACE 60F (E) BUILDING DRAIN
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 1 # $25
Sewer, Sanitary 1 PRSEWER 1 # $25
TOTALS: $50.00
1 71
r a.
Plumb.Plan Check 0.0 hrs $0.00
e;' ,,Fee,- Plumb.Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hrs $48.00 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-for addn'l info.
FEE ITEMS (Fee Resolution 1.1-053 F_f. 7/1113) FEE QTY/FEE MISC ITEMS
Ph,in(.;Ise% k 1,e','.`
P(, I-'ee
PME Plan Check: $0.00
PME Unit Fee: $50.00
PME Permit Fee: $48.00
Administrative Fee: (ADMIN $45.00
Work Without Permit? ®, Yes 0 N $0.00
A'-Ivunc',`e, 7 l('a;ff nl';,€`£e¢,s:
Travel Documentation Fee: ITRA VDOC $48.00
Strong Motion Fee: IBSEISMICR $4.06 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $2.00
$197.06 $0.00 TOTAL FEE ' $197.06
Revised: 10/01/2014