15060122 CITY OF CUPERTINO BUILDING PERMIT
��W
BUILDING ADDRESS: 10571 STOKES AVE CONTRACTOR: — PERMIT NO: 15060122
I{�t�+Inl�i�v
OWNER'S NAME: KELLEY JON W AND EMILY L TRUSTEE i � f t J'CS— DATE ISSUED:06/17/2015
OWNER'S PHONE: 4088211711 QeOVVIODO C l A q PHONE NO:
JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
�"Q{ LICENSED CONTRACTOR'S DECLARATION REPLACE 25' OF 4"MAIN SEWER LINE AND INSTALL
License Class Lic.# � NEW
Contractor SNA w ?IKm i .17.1ZIf CLEANOUT
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
e¢ormance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3785
have and will maintain Worker's Compensation Insurance,as provided for by rl
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:32649024.00 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 180 S FROM LAST CALLED INSPECTIO
indemnify and keep harmless the City of Cupertino against liabilities,judgments, MgLO�5LX0
��
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
4—)
with all non-p('nt source r ula' ns p e Cupertino Municipal Code,Section
9.18.
P. f 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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. 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 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,Sect' ns 2550 25533�;�ate:
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: l �. 47-Z011
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 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
GENERAL PERMIT APPLICATION `,50601 D M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333• buildingecupertino.org MISC
CUPERTINO
*PLUMBING
^ ' MECHANICAL ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS I O g N f±y<fl;.
APN# (Z a
ul
OWNER NAME D vi t �I 11, t PHONE -<3v 1 , ) I E-MAIL
STREET ADDRESS �'� ( �XtS 1 /� CITY, STATE,ZIP �\I/ I[ / / (U I FAX
CONTACT NAME I (/I 17 C �,l/� 'A�/1/ PHONE ►I b )
STREET ADDRESS �� 1[t\DO/��^�/I n '/11/U CITW'M� �� CA_4/L A/ I Fly_ �jJ CJQ
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 11 ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMr LICENSE NUMBER ql jy'jS-,Cj LICENSE TYPC�_ BUS.LIC#
��""1 1' 1 �I V��•1 v' �� Cf/ I MAID. T(; \ ' 1i ,_ 1
STREET ADDRESS JMk -4�2 CITY,STATE,ZIP 1 ��^ ���/u,I to(b)
4(-U��
L�p
ARCHITECT/ENGINEER NAME 1 LICENSE NUMBER BUS.LIC#
COMPANY NAME I v E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN W ILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? �❑ NO
DESCRIPTION OF WORK
Ij
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the following: I an
the p operty owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have p vided is c ect. 1 a e rea the Descr' ion of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to bu in c ns tion. riz p sent s of Cupertino to enter the abov -Id tiffiie7d r�opee�rty for inspection purposes.
Signature of Applicant/Agent:
Date: ( �l1
SUPPLEM MAL INFORMATION RE IRED OFFICE USE ONLY
W OVER-THE-COUNTER
C6
F' ❑ EXPRESS
U
W ❑ STANDARD
x
U
< ❑ LARGE
C6
❑ MAJOR
MEPMiscApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10571 Stokes Ave DATE: 06/17/2015 REVIEWED BY: Paul
APN: 326 49 024 BP#: a "VALUATION: 1$3,785
'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPSS
USE: PERMIT TYPE:
WORK Re lace 25' of 4" main sewer line and install new cleanout
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 1 # $25
TOTALS: $25.00
Aleck. Plan Check Plumb.Plan Check 0.0 hrs $0.00 !:1ec..Plan Check
llech. Permit r., Plumb.Permit Fee: IPPERMIT Elec. Permit Fee
Other A4ech. Insp. Other Plumb Insp. 0.0 hrs $48.00 lrher Elec.Insp. Li
14ech. h7sp. Fee "htmh. 117sp. F6, !.Iec.Insp. Fee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Elf. 711113) FEE QTYIFEET- MISC ITEMS
Plan
:Supp/. PC P Cc'
PME Plan Check: $0.00
Permit Fee:
Supp/. hts/>Fry
PME Unit Fee: $25.00
PME Permit Fee: $48.00
('ottstructi017 7'n.r:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
Advan
Travel Documentation Fee: ITRA VDOC $48.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $167.50 $0.00 TOTAL FEE: $167.50
Revised: 05/07/2015