14100045CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 840 ROSE BLOSSOM DR
CONTRACTOR: BENJAMIN FRANKLIN
PERMIT NO: 14100045
PLUMBING
OWNER'S NAME:
NOVATO, CA 94949
PHONE NO: (415) 506-0400
❑, LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
PROPERTY LINE CLEAN OUT
License Clasps_ Lic. # RS -735-7
Contractor YJ Date �b I � 0 11
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
erformance of the work for which this permit is issued.
Sq. Ft Floor Area:
Valuation: $3000
ve and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 35904019 00
Occupancy Type:
ction 3700 of the Labor Code, for the performance of the work for which this
ermit 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
WIT , RMIT 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 D S FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
bL-1
costs, and expenses which may accrue against said City in consequence of the
Id g
Issued by: Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
RE- OFS:
9 18.
_
�o
Date
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.
ElOWNER-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.
0 b 2d I
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
CITY OF CUPERTINO
,y-.. FEE ESTIMATOR — BUILDING DIVISION
imlADDRESS:
840 rose blossom dr
QTY/FEE
DATE: 10/08/2014
REVIEWED BY: Mendez
BP FEES
APN:
BP#:
*VALUATION: $3,000
PERMIT TYPE: Plumbing Permit
1
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE: p
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
propertv line clean out
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Other Plumb Insp. 0.0 hrs $48.00 ofb("P l r< - hsv' E3
Sewer, Sanitary
1PRSEWER
1
#
$25
�gV.:P'lni i ce:Z
t
suI)PI, hol')
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
Coll."'frljchon TUX:
T -F
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$25.00
Strom Motion Fee: IBSEISMICR
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Fewer District, Schooi
or„ i Thoco foot aro hacod an the nroliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 U. 7/1/131
'l K.. 0
Plumb. Plan Check 0.0 1 hrs $0.00 1 ev.1'
QTY/FEE
f n1�t Fee'
Plumb. Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hrs $48.00 ofb("P l r< - hsv' E3
:Shc )p . PC I,''Ee
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Fewer District, Schooi
or„ i Thoco foot aro hacod an the nroliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 U. 7/1/131
FEE
QTY/FEE
MISC ITEMS
IpICZY} cf
:Shc )p . PC I,''Ee
PME Plan Check:
$0.00
�gV.:P'lni i ce:Z
t
suI)PI, hol')
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
Coll."'frljchon TUX:
T -F
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes 0 No
$0.00
Travel Documentation Fee: ITRAVDOC
$48.00
Strom Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
7jjjj���F$1167.50,$0.00
; TOTAL FEE:
$167.50
71
Revised: 08/20/2014