15040123 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18841 ARATA WAY CONTRACTOR:AMERICAN PERMIT NO: 15040123
RESIDENTIAL SERVICES OF CA
OWNER'S NAME: THOMPSON ZORA TRUSTEE 965 RIDGE LAKE BLVD STE 201 DATE ISSUED:04/16/2015
OWNER' ONE: 4082539928 MEMPHIS,TN 38120 PHONE NO:(408)982-0405
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL
REPLACE/REPAIR(E)SEWER LINE BETWEEN
License Class Lie-# FOUNDATION&
PROPERTY LINE&INSTALL(N)PROPERTY LINE
Contractor�i�?Gr/� '� Date CLEANOUT.
I hereby affirm that I am licensed under the provisi s of C apter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
Ihereby affirm under penalty of perjury one of the following two declarations: SAN In TA RY
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:$5400
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:37512033 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 WITII N 1 + + 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 S FROM LA LED 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:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point sourco regulations per the Cupertino Municip Code,Section
918,
RE-ROOFS:
SignatureDate ` All roofs shall be inspected prior to any roofing material being installed.If a roof is 2� _
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. 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 unicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25 05 d 25534. �i l
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: �v `
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
4PPLICATION V
0
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTI[VC3
(408)777-3228• FAX(408)777-3333•buildingacupertino.ora
P LO ,•/Y�►'/�{ JfC /10�
PROJECT ADDRESS I�Wl ,//y,� � APN# �I / _ O '33
OWNER NAME PHOG��NE �- / E-MAIL
STREET ADDRESS CITY,STATE,ZIP w / jy/ FAX
CONTACT NAME PHO - E-MAIL
STREET ADDRESS �/ CITY,STATE,ZIP FAX
• ❑OWNER ❑ OWNER-BUILDER ❑ oWNERAGENT R__t�CTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME `' LICENSE R LIC E BUS.LIC#
COMPANY NAME ('{�// E-MAIL FAX
STREET ADDRESS CrM STA ,Z 141 P 0
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORKZ 46,k
USE OF ❑ SFD or Duplex Multi-Family ILLUMINATED SIGN TYPE NO.OF SIGN AREA VALUATION
STRUCTURE: ❑ Commercial (Y/N) (CODE) SIGNS (SQ.FT.) (s) G
SIGN TYPE CODES:
B - BANNER SIGN M -MONUMENT(GROUND)SIGN
BL - BLADE SIGN P - PROJECTING SIGN
D - DEVELOPMENT ID SIGN SP -SPECIAL EVENT BANNER
DI - DIRECTIONAL SIGN T - TEMPORARY
E - ELECTRONIC W - WALL SIGN
READERBOARD WI - WINDOW SIGN -
TOT UQOI
By my signature below,I certify to each of the following: I am the prop owner or authori 1 ent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin onstruct . I authorize representatives of Cupertino to enter the aboveolideritified property for inspection purposes.
Signature of Applicant/Agent: ���� Date: (G YJ
SUPPLEMENTAL INFORMATION REQUIRED 011WIN
_Site Plan
,...,. ,�?I Wei l?IGHEC SPI •$ �OU77G SLTp�: .,, ,++
'd.
Elevations `. ES$: ,� �a $ DCN LAN`BEVIE.
_Sign Details-including UL listing(s)applicable T? a �� Pi P>ANvnvwx `
C � .
Structural Calculations(if applicable)
Copy of Planning Approval Letter or Meeting with Planning prior to sox � �
submittal of Building Permit application. 5,7
q }rx F
SignApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 18841 ARATA WAY DATE: 04116/2015 REVIEWED BY: MELISSA
APN: 375 12 033 BP#: EVALUATION: 1$5,400
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION 1 RPSS
USE: p PERMIT TYPE: A
WORK REPLACE/REPAIR E SEWER LINE BETWEEN FOUNDATION & PROPERTY LINE & INSTALL N
SCOPE PROPERTY LINE CLEANOUT.
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $25
$2
TOTALS: 5 00 r �� _:
cc:h.Plan Check Plumb.Plan Check 0.0 hrs FIIPR
$0.00 E'lec.Plan(,'heck
Lfi.>ch. Pera it Fee>.. Plumb.Permit Fee: 1PPER1l1IT Elec. Permit El l ee:
F,lf,"'h.
fec�h.Insp.
Other Plumb Insp. hrs $48.00 Other/aec.Insp. Li
Ifzsh. Fee: Plumb. fila Tee: Dec.Ins*). Flee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 in o.
FEE ITEMS (Fee Resolution 11-053 E . 7ff 11/13) FEE QTY/FEE MISC ITEMS
Plan Check Feer:
tiSuppl. PC Fee
PME Plan Check: $0.00
Permit.Ir ee:
SuppL hasp Fee
PME Unit Fee: $25.00
PME Permit Fee: $48.00
Consiruction Tax:
F-7
Administrative Fee: IADMIN $45.00
Work Without Permit? ®Yes (E) No $0.00
.,Idvaneecl Planning Fees:
Travel Documentation Fee: 1TRAVDOC $48.00 A
Strong Motion Fee: 1BSEISMICR $0.70 Select an Administrative Item
Bldg Stds Commission.Fee: 1BCBSC $1.00
In
g A h _"N ON � n 7a. AL FEE 167.70
_ ,.,` $167.70 $0.00 3 $
Revised: 04/01/2015