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15070038 CITY OF CUPERTINO BUILDING PERMIT BCJILDING ADDRESS: 21871 COLUMBUS AVE CONTRACTOR:" PERMIT NO: 15070038 �1 h��I,I�It31,�IG�+I�f�TI I�; OWNER'S NAME: HEILMAN JOHN J AND FAUSTENE V , '` � ��T(�� l� DATE ISSUED:07/07/2015 OWNER'S PHONE: 4089738098 ��'�� `�� ' � PHONE NO: �– LICENSED CONTRACTOR'S DECL�RA"I'ION JOB DESCRIPTION:RESIDENTIAL � COMMERCI.AL � �a /, � REPLACE(E)CLEANOUT License Class C�� Lic.# �� Contractor �-�� r�/�7�', �7Y��(�Date ��1� -T�� r':., �� 1 hereby affirm that I am licensed under[he 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. �`. � y� ._� :.� r�,.. . .� G�. 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:$2000 � 1 have and will maintain Worker's Compensa[ion Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �pN Number:3�614030.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 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 relatinb 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 ig�D S FROM LAST CALLED INSPE T N. indemnify and keep harmless the City of Cupertino against liabili[ies,judgments, ,, I , costs,and expenses which may accrue against said City in consequence of the �L��5��(�� (�/V Date: � �JIJ��• granting of this permit. Additionally,the applicant understands and will comply Issued by: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. '� � RE-ROOFS: Signatu - %��*� Date�7—_�.� All roofs shall be inspected prior to any roofing material being installed. If a roof is installed wrthout first obtainmg an mspection,1 agree to remove all new matenals for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affrm 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) l,as owner of the property,am exclusively contracting with licensed contractors to HAZARDO[!S MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardoas materials requirements under Chapter 69_5 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 M1tunicipal Code,Chapter 9.12 and the deClarati0ns: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certitica[e 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 111anagement District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2550 , 55 , d 25534. Section 3700 of the Labor Code,for the performance of the work for which this � permit is issued. Owner or authorized agent� Date:�� 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. [f,af[er making this certificate of exemption,1 CONSTRLJCTION 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 applica[ion and sta[e that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construc[ion,and hereby authorize representatives of this city ro 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.I 8. Signature Date � GENERAL PERN[IT APPLICAT[ON �S�`��,`3� .. j1 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 � (408)777-3228 • FAX(408)777-3333 • buildina(�a.cupertino.orq CUPERTtNCi PLL7MBING ❑MECHAi��IC,�L ❑ELECTRICAL ❑A4ISCELLANEOliS PROJECT ADDRESS � � � �� APN� � O OWTER1QAlviE ' �.- PHO �� iy��, E-DtiAIL � STREET.ADDRESS CITY, STATE,Z1P � � �,�c_/� � //? // COI�'T.ACT N.A1vIE �� ' PHON _ E-MAIL � ��1�� STREET ADDRESS �� // CITY,STAT ` �l� / FAX I�f��L"� / 2 ✓ ❑ 01�R.'ER ❑ OR'T'ER-BUII.DER ❑ ORT'ER AGc.'�T ❑ CO?�TRACTOR �20?�'TRACTOR AGENT ❑ ARCHIIECT ❑ENGL\�EER ❑ D�'ELOPER ❑ TE\A.�'T COIVTRACTOR NA1�4"t L� �� LICENSE NUA�ER � LICE"'��''"^" BliS.LIC�� /�� C COMPA2�'1 NAME _ � G � � / E" � F - C'_f ' � STREET ADDRESS CITY, E,ZIP P \E � � 3� /�� r,�.�� /�- , ,�v�! h �/cs /` zr3 � - ARCHITECT/ENGL'��EER N.AME LICEt�'SE I�'UMBER BUS.LIC: COMPA?v'Y r'AME E'- FAk STREET ADDRESS _ __----"�""��^ �� CITY,STA'IE,ZIP PHOI�TE USE OF ❑SFD or DUPLFX ❑ DNLI I-F.4Affi,Y PROJECT P�W II.DLAN� ❑ YES PROJECT IN ❑ YES LS 1T�BLDG AN ❑ 1'ES BUII.DL�G: �COIvL�vTERCLAL URBAT�'II�'TERFACE AREA � T'0 FLOOD Z02�B ❑ NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK l( ._ !( � � � �/�� r� , . TOTAL VALUATION: ' � � � � _�s�� RECEIVED B] r �; By my signature below,I certify to eacb of the following: I am the property o�i�ner or authorized a�ent to act on the pr perty owner's behalf. I have read this application and tl�e infonnation I have provided is correct. I have read the Desciiption of Work and verify it is accurate. I a�ree to comply�i�ith all applicable local ordinances and state la��s relatin�to buildins construction. I authotize representati��es of Cupertino to enter the above-identified property for inspection purposes. Si�-nature of Applicant/Agent: Date: SU�PLEMENTAL L\'FOR�IATION REQUIRED o��rzcE os�o�:i:r � 0�'EF'.-"CIIE-COIi\TI:12 — —� E\PRE:jS — ❑ >T,a\;)nF:D , z ,� � = L:�kGI: — �� '�i�JOR� A7EPA7iscApp_1011.doc re>>ised 06/21/11 CITY OF CUPERTINO �°��`�Q�� ' � FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 21871 COLUMBUS AVE DATE: 07/07/2015 REVIEWED BY: Paul � APN: 356 14 030 BP#: �VALUATION: $2,000 PERtitI"I��TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRI MARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 RPS� WORK Re lace E cleanout SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $25 � TOTALS: $25.00 Plumb. Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMlT : , Other Plumb Insp. 0.0 hrs $48.00 NOTE: This estimate does not include fees due to other Departments(i.e.Plnnning,Public Works, Fire,Sanitary Sewer District,School District,etc . These ees are based on the relimina in ormation available and are onl an estimate. Contact the De t or addn'1 in o. FEE ITEMS �Fee Resolu�ion 11-0.i3 Efj� i:��l"l3) FEE QTY/FEE MISC ITEMS � � r:� . PME Plan Check: $0.00 t�: PME Unit Fee: $25.00 PME Permit Fee: $48.00 Administrative Fee: IADMIN $45.00 Work Without Permit? � Yes � No $0.00 Travel Documentation Fee: ITRAVDOC $48.00 � � Strong, Motion Fee: 18SE/SN11CR $0.50 � Select an Administrative Item t31d<� Stds Commission �ee: IBC'�3SC $1.00 � SUBTOTALS: $167.50 $0.00 TOTAL FEE: $167.50 Revised: 07/02/2015