15030186 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11850 UPLAND WAY CONTRACTOR:MIKE COUNSIL PERMIT NO: 15030186
PLUMBING INC
OWNER'S NAME:
SAN JOSE,CA 95131 PHONE NO:(408)272-4900
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
f �7 REPLACE PORTION OF MAIN WATER LINE FROM
License Class Lie.# 1 METER TO
t_
IST PUMP(165 L.F.)
Contractor. Date
I hereby ,ffirm t at I am licensed under the provisions of Chapter 9
(commen 'ng wj&Section 7000)of Division 3 of the Business&Professions
Code and t 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:$39000
ve 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:36603025 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 IT 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 DAY ALLED 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 Date: 3 3U �
granting of this permit. Additionally,the applicant understands and will comply
with all non- int source regulations per the Cupertino Municipal Code,Section
918.
3� ,{ RE-ROOFS:
Signature Date ) 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 a arm 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 complian 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 Co , 25 and 25534.
Section 3700 of the Labor Code,for theerformance of the work for which this
p Owner or authorizeda 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 CO TR CTION 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
918.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 11850 UPLAND WAY DATE: 03/30/2015 REVIEWED BY: MELISSA
APN: 366 03 025 BP#: 'VALUATION: 1$39,000
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPW
WORK REPLACE PORTION OF MAIN WATER LINE FROM METER TO 1ST PUMP 165 L.F.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1 BPWSVCS 1 # $25
TOTALS: Ig
- $25.00
011111MM-1,SM
Meckr. Plan C kieck Plumb.Plan Check 0.0 1 hrs $0.00 Pian Check
blecti. Perwil Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit Fee:
Orher Akch. trap Other Plumb Insp. 0.0 hrs $48.00 Ofker 1"lec.Insp. EIF
.14cch. h2sp. Fee: Phinib. Insp. Fee: kkc.Insy'), Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These ees are based on the prelinddha information available and are only an estimate Contact the Dept-for addn'l info,
FEE ITEMS(Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Pee:
.5uppl. .P('I"Ccs
PME Plan Check: $0.00
Permit Fee:
suppl 111sp Fee
PME Unit Fee: $25.00
PME Permit Fee: $48.00
C'onso-uction TUX.
Administrative Fee: IADMIN $45.00
Work Without Permit? ® Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $5.07 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $2.00
" t $173.07 $0Emil N
.00 TO SAL FEE: $173.07
Revised: 02/14/2015