15010109CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22276 HARTMAN DR
CONTRACTOR: MIKE COUNSIL
PERMIT NO: 15010109
PLUMBING INC
OWNER'S NAME:
SAN JOSE, CA 95131
PHONE NO: (408) 272-4900
Id LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E]
r j
License Class - Lic. # (0 1
REPLACE (E) BUILDING & SANITARY SEWER LINES &
INSTALL 2 CLEANOUTS (FOUNDATION & PROPERTY
�W%&A 0 L� `ZD (S
LINE
Contracto*►V_e CL1U ,5l, 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.
CA
I hereby affirm under penalty of perjury one of the following two declarations:
N I TARY
I have and will maintain a certificate of consent to self-insure for Worker's
%al/mv
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $35000
performance of the work for which this permit is issued.
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: 32613086 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
LED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments
costs, and expenses which may accrue against said City in consequence o
ed b Date: Z
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.
U'�k '�RE-ROOFS:
Signature DateAll
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)
1, 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. 1 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
Date:Ot Lk lzdl,
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
CONS UCTION 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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
CITY OF CUPERTINO
WNW FFF ESTIMATOR — BUILDING DIVISION
22276 HARTMAN DR
DATE: 01/21/2015
REVIEWED BY: MELISSA
liaADDRESS:
APN: 32613 086 BP#:
"VALUATION: 1$35,000
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
PENTAMATION
1 RPS
USE:
$25
PERMIT TYPE:
WORK
REPLACE E BUILDING & SANITARY SEWER LINES & INSTALL 2 CLEANOUTS FOUNDATION &
SCOPE
PROPERTY LINE
#
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Sewer, Building
1PRSEWER
1
#
$25
Sewer, Sanitary
1PRSEWER
Sapp/? Inrp I'ee
1
#
$25
PME Unit Fee:
$50.00
PME Permit Fee:
$48.00
('on:;Irllction KIN.'
Administrative Fee: IADMIN
$45.00
Work Without Permit? ® Yes (2) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$50.00
Strong; Motion Fee: IBSEISMICR
07/1' r ;V('<:ja. 7r. y,.n"
Plumb. Plan Check 1 0.0 1 hrs $0.00 1 "_gin (:r cek
Plumb. Permit Fee: 1PPERMIT ;.< _> < F`°;'
Other Plumb Insp. 1 0.0 1 hrs 1 $48.00 Ur77t�r Et�:r . Ir7.r �.
Plumb. Itt.sp. Fee:
1"7('-1(. 1r7sp. I'_ e
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Pire, Sanitary Fewer District, School
Metri/H oto) Thoco fooc aro haeod nn tho nroliminnn) lnfnrrnatinn availahlo and aro nnly an o.ctimato_ Contact tho Dant fnr addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Ilan Check Fee:
Sz ppl. I'C: 1 `
PME Plan Check:
$0.00
Sapp/? Inrp I'ee
PME Unit Fee:
$50.00
PME Permit Fee:
$48.00
('on:;Irllction KIN.'
Administrative Fee: IADMIN
$45.00
Work Without Permit? ® Yes (2) No
$0.00
/lCdvaliccd Planning I`ecm:
Travel Documentation Fee: ITRAVDOC
$48.00
Strong; Motion Fee: IBSEISMICR
$4.55
Select an Administrative Item
Bldg Stds Commission .Fee: IBCBSC
$2.00
>r $�
$197.55
$0.00 TOIL FEE:
$197.55
Revised: 01/06/2015