14110133 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10141 PRADO VISTA DR CONTRACTOR:ABLE SEPTIC PERMIT NO: 14110133
OWNER'S NAME:
SAN JOSE,CA 95110 PHONE NO:(408)377-9990
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
^-� SEWER REPAIR
License Class 6f 1 2 Lie.# / 7
Contractor Date
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:$4500
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:34214107 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 0 DAYS O 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 OM 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 d
granting of this permit. Addy ,ionally,the applicant understands and will comply Issued by: Date:
with all non-point source lations per the Cupertino Municipal Code,Section
9 18.
1 RE-ROOFS:
Signature Date l/ y <� 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,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 Cu ertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 05,25533 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
Compensation laws of California. If,after making this certificate of exemption,I CON TR/CN 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
CONSTRUCTION PERMIT APPLICATION 1
10\
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(cDcupertino.org \1�
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS n \ p.C `,` � v- t) � APN# 3,q� I-1 10
OWNERNAME
STREET ADDRESS CITY, STATE,ZIP FAX
MIM Ryadfs S ty
CONTACT NAMEV P[ipNE LA M
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-MAiL r1 e r,w m
STREET ADDRESS CITY,STATE, ZIP FAX l 1 r/t
1 fr c aNO 9M Lf ti 2,-100
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT La.CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LI K SELTYPE BUS.LICmoay-
# t�
COMPANY NAME�`_ ``I� ��` _ (`M) E 1"\" (X�1 f ��.t o Y t FAX 40 b-Liq 100 e,
STREET ADDRESS 1 �C l� Y C STATE,ZIP PHONE v� `1 D
i F Qc>Vv\ o6e c� q51
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
EXISTING USE PROPOSED USE CONSTR TYPE 1 #STORIES
USE TYPE OCC. SQ.FT. VALUATION(5)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA I DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECONDST ❑YES
BEINGADDED? []NO ADDITION? []NO
PRE-APPLICATION DYES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVLO.B ." TOTAL VALUATIO
PLANNINGAPPL# ONO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO ":I-
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have nrovited is confect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: D te: ! 2 7
SUPPLEMENTAL rwORWATION REQUIRED ROUTING sig
_New SFD or Multifamily dwellings: Apply for demolition permit foroR-TxE-t ouNTeR ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of buildin
permit for new building. I3"ExPREss ❑ pI ANNINGPLANREVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STritiiARn ❑ ktisLlc woxxs
form if any Hazardous Materials are being used as part of this project. t
.LARGE` ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MAJOR 13 SANITARY SEWER DISTRICT
❑ ENV11R0MWNTAL`HE1LTH
BidgApp_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10141 prado vista dr DATE: 11/24/2014 REVIEWED BY: Mendez
APN: BP#: "VALUATION: 1$4,500
*'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPS
USE: PERMIT TYPE:
WORK sewer repair
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $25
TOTALS: $25.00
— g ,g
(((J?, ,r'Icrrr Check Plumb.Plan Check 0.0 hrs $0.00 1':/ec. /'/'v?Check
1'>rwit Dere: Plumb.Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hrs $48.00 t>,i_er Lfc, Tis>.
/'/11111h. Trip, Fee
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the prelhiniina information available and are only an estimate Contact the Dept-for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
suj pSl, Iusp 1"',
PME Unit Fee: $25.00
PME Permit Fee: $48.00
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRAVDOC $48.00
Strang Motion.Fee: IBSEISMICR $0.59 Select an Administrative Item
Bide;Stds Commission.Fee: IBCBSC $1.00
r
$167.59 $0.00 TOTAL FEE: $167.59
Revised: 10/01/2014