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150700841 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10561 CULBERTSON DR CONTRACTOR: AMERICAN PERMIT NO: 15070084 RESIDENTIAL SERVICES OF CA OWNER'S NAME: AMCHISLAVSKY MIKHAIL 965 RIDGE LAKE BLVD STE 201 DATE ISSUED: 07/13/2015 OWNER'S PHONE: 4082420805 MEMPHIS, TN 38120 PHONE NO: (408) 982-0405 Iff LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑ 7 INSTALL NEW PROPERTY LINE CLEANOUT & T OF License Cl as 3 Lic. # �f ��� S BUILDING SEWER LINE Contractor �S 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 Sq. Ft Floor Area: Valuation: $4845 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: 37536019.00 Occupanc) 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 180 DRYS FROM LAST C LED INSPE TI N. 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 granting of this permit. Ad Tonally, the applicant understands and will comply Issued by: Date: Cupertino Municipal Code, Section with all non -point source r la�77 9.18. 3 ^ Signature % �'" Date RE -ROOFS: 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: 1 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 1, 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 Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 255 , 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Dater `'5 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 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 GENERAL PERMIT APPLICATION II COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVOT 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(@-cupertino.org �SLUMBINCT ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PRO iECT ADDRESS, — \ APN R rK� 2/ ✓ f 0 OWNERNAME J PHO E-MAILL4 0 2,q 74-A4 STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE [ q E-MAIL r y ()� STREET ADDRES U. CITY, STATE, P � ❑ ONVNER ❑ OWNER -BUILDER ❑ OWNERAGENT ©CONTMACTOR ❑co,,rRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAI VLIC S F,$ LICENSETYP BUS. LIC# iT COMPANY NAME E-MAILS FAX STREET ADDRES O CITY, STATE, ZIP PHO ARCHITECT/ENGIN'EER NAME LICENSE NUMBER BUS. LIC n COMPANTY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN W ILDLAND ❑ YES PROTECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK r rt'1� e V, ©J TOTAL VALUATION: / RECEIVED BYa� By my signature below, I certify to each of the fo wine: I am the property owner or authorized agent to act on the p perry owner's behalf. I have read this application and the information I have provided 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 build' nstructio I authorize representatives of Cupertino to enter the above -identified roperty for inspection purposes. �--`- Signature of Applicant/Agent: % Date: 1 SUPPLEMENTAL INFORMATION REQUIRED ' 3OVER " THE CQUJTE2 ,.� V F $XPRE S' k*Rm�MINI._� ,. a�'a{ t ,6M� 70R0 AlfEPA1iscApp_201 1. doc revised 06121/11 CITY OF CUPERTINO )'� Fm FEE ESTIMATOR — BUILDING DIVISION 19' ADDRESS: 10561 Culbertson Drive DATE: 07/13/2015 REVIEWED BY: Paul UNITS APN: 375 36 019 BP#: *VALUATION: 1$4,845 xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: I PENTAMATION 1RPSS I PERMIT TYPE: WORK Install new property line cleanout & T of building sewer line SCOPE Sur' ' I APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES Elec. Permit 1,: Sewer, Building 1 PRSEWER ?thee Elec. Insp. Li 1 # $25 Permit Fee Sur' ' I PME Unit Fee: $25.00 PME Permit Fee: $48.00 � <.-,,,ruction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $25.00 Strong Motion Fee: ]BSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution II -053 Eff 7,11/13) Mech. Plant Check Plumb. Plan Check 0.0 1 hrs $0.00 IJec. Plan Check FechPermit F : Plumb. Permit Fee: IPPERMIT Elec. Permit 1,: Other A4ech. Irtsp. Other Plumb Insp. 0.0 hrs 1 $48.00 ?thee Elec. Insp. Li i't � 1po> !' I' PME Plan Check: 'r O3 u'. F"c NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution II -053 Eff 7,11/13) FEE QTY/FEE MISC ITEMS Plun C hc'ck J,,,;" Suppl. Pt"' Fee PME Plan Check: $0.00 Permit Fee Sur' ' I PME Unit Fee: $25.00 PME Permit Fee: $48.00 � <.-,,,ruction Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? Yes 0 No $0.00 =t c to t='Iarirun�7 Fees, Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: ]BSEISMICR $0.63 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $167.63 $0.00 TOTAL FEE: $167.63 Revised: 07/02/2015