14100140 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10101 SCENIC BLVD CONTRACTOR:ABLE SEPTIC PERMIT NO: 14100140
OWNER'S NAME: 1020 RUFF DR DATE ISSUED: 10/23/2014
OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)377-9990
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
�7r PROPERTY LINE CLEAN OUT
License Class �- q-2 Lic.# /_(�7 7
Contractor pA 1314? tc- Date / O- .1
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$8900
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:35709003 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 M 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: G Date: �d i
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date O 23All 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.
❑ WNER-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
1,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 the Health&Safety Code,Sections 255 ,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:l0
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 a Mm�4.v-�... 0OMMUN7Y DEVELOPMiENT DEPAR TMEis i• BUILDING DIViSION
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By-,p simathlre belga,I ce,:if!to BBch of the followLng: I am u`e prope.rty ov%mmr or authorized a.ent to Pct on the property oy,mer's be _If. I hFvt read thus
c_'up;lCcilOA and she info z auto]I ha;=e ar ovidtd CO:eCt I have read the DeSCi i?ilOD of-Work and verify it i5 aCC'rite. I auee to coW. y with all applica-ble local
Or dmances and state i\i5 relatm-to b' H 1 u.1ci7Dn. I auiho,^. e reps eSent,—vcS of Ci]pe1?in0 to enter$le above-Sdei1`ed p:07e—iY for 1?S:?e-_,;on-oores.
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53
Jk f_FPA1'scEpp_2011.eocreuised 06/1l/II
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10101 scenic blvd DATE: 10/23/2014 REVIEWED BY: Mendez
APN: BP#: *VALUATION: 1$8,900
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPS
USE: PERMIT TYPE:
WORK �mpertyline clean out
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $25
TOTALS: $25.00
gumNas a w .. r
A
IN ice.'-...,. z4"..'�i.. 14wSNkfs rv.ds 4..;�.
Plumb.Plan Check 0.0 hrs $0.00 Alec, Pio'-Check
;tlecl;. Me'fWl Fee: Plumb.Permit Fee: IPPERMIT =ir 1, z<
C'Mm"r r11cch. h-I'mL-1 I Other Plumb Insp. 0.0 hrs $48.00 Urher�J.'Xc. lnsp, E3
tI"ch, Inv). %'htinrh h7sp. tee: Eh,'(".lns,
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelimWina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E : 7/1/131 FEE QTY/FEE MISC ITEMS
11f)I)d. PC PIV
PME Plan Check: $0.00
P-i rail F T
PME Unit Fee: $25.00
PME Permit Fee: $48.00
C.C13Z.Siroc'iion /41,v:
Administrative Fee: 1ADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $1.16 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
'„ $168.16 $0.00 TOTAL FEE:, $168.16
Revised: 08/20/2014
SMOKE / CARBON MONOXIDE ALARMS '
OWNER CERTIFICATE OF COMPLIANCE �j'Z�' lel
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
GUPERTiNO ' �,
10300 TORRE AVENUE•CUPERTINO CA 95014-3255 G'
(408)777-3228•FAX(408)777-3333•buildingna.cupertino.org d 0
Permit N
Address �� n 156P-a)IG V' -I`t 1110 #of Alarms Smok Carbon Monoxi z
r
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,20.13 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations,or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s)
On every level of a dwelling unit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes.The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to comply with the terms and conditions of this statement
O elmwn r(or Owniw"er Agent's)Name:
-�
... .................................................................................Date: .................
Contractor Name:
Signature...................................................................Li c.#......................................Date: ...................
Smoke and CO form.doc revised 03/18/14