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15060180 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20225 NORTHGLEN SQ CONTRACTOR:MIKE COUNSIL PERMIT NO: 15060180 PLUMBING INC OWNER'S NAME: HOLSINGER ROY W 1915 OTOOLE WAY DATE ISSUED:06262015 OWNER'S PHONE: 4084463089 SAN JOSE,CA 95131 PHONE NO:(408)2724900 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ ' 1 & �n I REPLACE(E)BUILDING AND SANITARY SEWER LINES License Class Io Lic.# `� Contractor Date �o I hereby (firm fh t I am licensed under the provisions of Chapter 9 (comme ing wi Section 7000)of Divition 3 of the Business&Professions Code and my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: SANI N)k 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:$29044 ave 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:31639006.00 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 mom to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save D 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 6 Zb granting of this permit. Additionally,the applicant understands and will compl at with all non- int source regulations per the Cupertino Municipal Code,Section 9.18. / RE-ROOFS: Signatur Date l0 l / 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. ❑ O ER-BUILDER DECLARATION I hereby affir 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) 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: l lealth&Safety Code,Section 25532(x)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 wit a Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se '0 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this z Owner or authorized age t: 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 Compensation laws of California. If,after making this certificate of exemption,I CON TRUCT ON LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a cN&91<ction 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 MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC (408)777-3228• FAX(408)777-3333•building(aDcupertino.org D CUPERTlNO ip /��G LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN# 3 I Q _ OO OWNER NAME �1 Y PHO o g q o C E-MAIL l a STREET ADDRES r/ Z2� _ IU N f CITY, STAT�,ZIP �� ' �O �� r0/� FAX CONTACT NAME (/ ' ��J 7 r PHONE L-MAIL` STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWIN'ER ❑ OWNER-BUMDER ❑ OWNERAGENT CONTRACTOR ❑COIN'TRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR TTAME LICENSE NUMBER LICENSE TYPE BUS.LIC i I�d,0FTAME Co ,1 4? 1 V�^ e el ��, 2 —3� COMPANY NAME E-MAIL FAX STREET ADDRESS/ D r,/ l C �4 CITY,STATE,ZIP A,k T/ r e PHONE T"!�D � uv d o� 2�z ygno ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF El or DUPLEX EIMULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN El YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE El NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK sem r ►"� '� l {� C e -1-� 4L et^ ode = f r>) -4 4-6 r '4 TOTAL VALUATION: EIVED By my signature below,I certify to each of the following: I am the property owner or authorized owner's behalf. I have read this application and the information I have tKovided is correct I have read the Description of Work a1 verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b 7 ' g onstruction. I authorize representatives of Cupertino to enter the abov identified p perty for' tion purposes. Signature of Applicant/Agent: Date: 2 Nat PLEA ENTAL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER c, ❑ EXPRESS U ❑ STANDARD U' ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 20225 NORTHGLEN SQ DATE: 06/26/2015 REVIEWED BY: MELISSA APN: 316 39 006 BP#: D� 'VALUATION: $29,044 xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: I PERMIT TYPE: WORK REPLACE E BUILDING AND SANITARY SEWER LINES SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $25 Sewer, Sanitary 1 PRSEWER 1 # $25 TOTALS: -7 $50.00 Mech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec. Plan Check Mech. PertniE F Plumb.Permit Fee: IPPERMIT Elec. Permit 1, rer;ilec h. Insp. Other Plumb Insp. 0.0 hrs $48.00 Other I;lec. Insp. 4"ch, Insp. Fee: Plivith. hrsp. Fee- Elec. 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 E.� 711!13) FEE QTY/FEE MISC ITEMS ,''ktn Check Fee: SuFpl. PC I'ee PME Plan Check: $0.00 %'c,rmit Fee: iipp1. Insp Fee PME Unit Fee: $50.00 PME Permit Fee: $48.00 ontstruction Tax: Administrative Fee: IADMIN $45.00 Work Without Permit? © Yes (j) No $0.00 Travel Documentation Fee: ITRA VDOC $48.00 Strong;Motion Fee: IBSEISMICR $3.78 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $2.00 SUBTOTALS: $196.78 $0.00 TOTAL FEE: F $196.78 Revised: 05/07/2015