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14100200CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10245 SCENIC BLVD CONTRACTOR: PHILLIP D BJURMAN PERMIT NO: 14100200 OWNER'S NAME: 1250 HIGHWY 101 DATE ISSUED: 10/31/2014 OWNER'S PHONE: AROMAS, CA 95004 PHONE NO: (650) 906-7533 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] PROPERTY LINE CLEAN OUT # � L.7 V License Class Lic. � Contractor Date t>t 1 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: $8000 d will maintain Worker's Compensation Insurance, as provided for by Phatv ion 3700 of the Labor Code, for the performance of the work for which this APN Number: 35702003 00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is S NOT STARTED PERMVMLAS correct. I agree to comply with all city and county ordinances and state laws relating WITIT 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 ED 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 Iss ed 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 9 18. Signature?, X/__— Date 6/_31 �� RE-ROOFS: All be inspected to any roofing material being installed. If a roof is roofs shall prior 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 the Health & Safety Code, Sections 25505, 25533, and 25534. y Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: r• � 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 9 18. Signature Date CUPS.ftTI t0 CENEP, AL PERMIT AIPPL[GA T IOC COMMUNITY DEVELOPIOENT Di=PAR T MENET • BUILDING DIVISIOI-. 10300 TORRE AVENUE - CUPERTINO, CA 950141-325-5 (=08) 777-3228 - rr� (!08) 777 7-3333 - buildino®cuo=rflno.ora I IPuu'1Jmm-n F�iaawoic.kL ❑�,-c,iva,&T I ll.M Cmi :-ik� 7souS (�2 r�>t' . S3tu �. I 35-7•00 03 CONTACT l ci,S ( P D's. ST7 �DDR�3S I C=1 , STAT' Z3 13�V.'T .ire '1 ❑ ro?-: �� c -m ❑ m7i Cm—, A.==z ❑ A.?.0=ST: Ci' ❑ C ❑ 1:3 R1J� • 0-k "A M�A1�.1r�Cc-.S'sl�ulr IC=s SBT?3 BUS. -1 C 0 ?HONE ,� �cz;�cr_ cr. I.AI✓� I ulcer s� l�� },��. BI: S. uc I 1 READD?SS I CITY, STAir, Z? I PHONE VSB Or ❑ sm or DUPL �: Vm-n-rA2omy 3V1T�L�C. ❑ COA�e aey I PR J-mCT R W'ii -DLA-Nm ❑YES I P?.0.rnCT A ❑ Yss t,?.3 t!, D.�s 4C Apalk ❑ I`o ::..OBD ZO}`: ❑ No I isi _ BLDG AN ❑ % s FiG� _e' Rolla?❑ No D SQIP r0?3 OF 1i 03KCOA" W TO ?t=om -^i _--.- y By my si_marz-e Belo . I ceoff y to each o? tl-,e following: u:, t I Le prope.-ty-�, earner or au'�oriz4d Pp- t to act on the propertyo�,•,-,er's behalf I have read tn_s _pplicatron and the info.-ne6on I have provided is co evt. I have read Lhe Des :p:non of ` orrl, and vel,`J it }5 a�C�at°. 1 a� ee to co -only W.-th all /Lnl+.cable local state la ^l Q ` e zction. I auLho; =e regresert rives of Cuger:ino to enter r_he abon-ide:,a=red cger `or Ls ecien g_�oses. �: Q1nGn'.�.e$ and ^t.^. � i'5- rr atL-I - 5 iz*_re 01. --pp lic=,t `-_Qe^.t: ' Da_e: i TEr,T, i b -.11 F SLAP h ;� �.I.�i-ORAA 0?v R,QU�D • -,•cam- c - _ , --- __ M-_—� 14 �A1 I.GOC revise 061:1111 CITY OF CUPERTINO FFF. FCTIMATOR — RITII,DING DIVISION im,ADDRESS: 10245 scenic blvd QTY/FEE DATE: 10/31/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$8,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex PENTAMATION 1 RPS PERMIT TYPE: 19 WORK ert I line clean out SCOPE �ro APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $25 TOTALS: $25.00 Plumb. Plan Check 0.0 hrs $0.00 11,>rvrrit Fee: Plumb. Permit Fee: IPPERMIT 0"irer H(jA fpn!". Other Plumb Insp. 0.0 hrs t,i�u.i�. I;il>. !"a". T17170. NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, sanitary sewer Distract, scnool es.. ) Th— f— Oro hacod nn tho nroliminary infarmadnn availahle and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 f 71 11113) FEE QTY/FEE MISC ITEMS Man Check s6ppl. PC Fk'c' PME Plan Check: $0.00 PME Unit Fee: $25.00 PME Permit Fee: $48.00 T -T Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes 0 No $0.00 c.hl'i7{tt`c',Ll Ph Fees: Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: 1BSEISMICR $1.04 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 Will $168.04 $0.00 TOTAL FEE•j $168.04 Revised: 10/01/2014