14120061 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20810 PEPPER TREE LN CONTRACTOR:CUPERTINO PLUMBING PERMIT NO: 14120061
OWNER'S NAME: MICHELE LUM 2784 S BASCOM AVE DATE ISSUED: 12/11/2014
OWNER'S PHONE: 4083152960 CAMPBELL,CA 95124 PHONE NO:(408)253-0618
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL EJ COMMERCIAL ❑
COPPER REPIPE WATER MAIN
License Class C_ 3 Lic.# C - y U
Contractor �" (L✓ Vl v-, 017:S. Date VZ — I I— 1 Y
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:$5000
ave 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:35911041 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT E IBES ORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 S 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 F LAST CALLED INSP CTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
LL
costs,and expenses which may accrue against said City in consequence of the Issued b
granting of this permit. Additionally,the applicant understands and will comply Y Date: (!
with all non-point source re ons the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date /Z ��^ 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 lity Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupert' icipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cod Section 5 nd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authoriz ent: Date: ,2—1r—/
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
918.
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �U
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MIS
GUPERTlNO (408)777-3228•FAX(408)777-3333•buildingIC
a(�cupertino.org \V
PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESSh APN# 3,5q 11 �
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OWN NA�yIE V PHONE 17 E-MAIL
rGtti.e-t le- L.c�rrt1-409,315-2—/6
STREET ADDRESS CITY, STATE,ZIP FAX
CO CT NAME ��!! PHONE E-MAIL
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STREET ADRESS l CIT STATE,ZIP _ FAX
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❑OWNER ❑ OWNER-BUILDER ❑OWNER AGENT P.-CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME FsµI �C LICE E NUMBER-o5 LICENSE TYBUS.LIC#
COMPANY NAME E-MAIL FAX
STREETRCITY,STATPHONE
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ARCHITECT/ENGINEER NAME LICENSE
BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT INWILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
A4,:Z� m 4 t n
TOTAL VALUATION: R£CE7VEDB
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By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pro owner' ehalf. I have read this
application and the information I have provided is correct. I ha-y&q0 the Description of Work and verify it is accurate. I agree ply with all applicable local
ordinances and state laws relating to Ing cons r esentatives of Cupertino to enter the above-identified property
yfor inspection purposes.
Signature of Applicant/Agent: Date:
SUPPUMENTAL INFORMATION REQUIRED oFPiGE.vsE
ONLY 4
T z SCI OVER TEIE-COUNTER _'
% D EXPRESSy' � .
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20810 PEPPER TREE LN DATE: 12/11/2014 REVIEWED BY: MENDEZ
t9jAPN: BP#: *VALUATION: $5,000 -�
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPRP
USE: p PERMIT TYPE:
WORK COPPER REPIPE WATER MAIN
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Re-Pipe Interior 1PRREPIPE 1 # $14
TOTALS: $14.00
Plumb.Plan Check 0.0 hrs $0.00 tae"_1' Ch` c
Feer. Plumb.Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hr s $48.00 01b.""r°r k:� ?i1T,
a,�t«.,z i•tsp- 1;�r: Thu�dj, hasp. tee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
f't,rinil F aee,
PME Unit Fee: $14.00
PME Permit Fee: $48.00
Coli'm'ucll on Tax: F
Administrative Fee: 1ADMIN $45.00
Work Without Permit? ® Yes (j) No $0.00
Travel Documentation Fee: ITRAVDOC $48.00
Strom Motion Fee: IBSEISMICR $0.65 Select an Administrative Item
BldgStds Commission Fee: IBCBSC $1.00
$156.65 $0.00 TOTAL FEE:' $156.65
Revised: 10/01/2014