15040167 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20777 FARGO DR CONTRACTOR:DRAIN DOCTOR PERMIT NO:15040167
OWNER'S NAME: LEE CROTHERS 480 ALDO AVE DATE ISSUED:04/22/2015
OWNER'S PHONE: 4082532832 SANTA CLARA,CA 95054 PHONE NO:(408)370-3082
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL ❑
INSTALLATION OF PROPERTY LINE CLEAN OUT.
Contractor �'� L"t;;,,;:.3 It,.. ,;. ,. afa' a- �n
la
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
Xerformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3100
+' 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:32630127.00 Occupancy Type:
permit is issued.
� APPLICANT CERTIFICATION
_ e'e�tify 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 DAYS FROM LAST CALLED 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 Issued b ��/T/V /��i G/7 Date: r�
granting of this permit. Additionally,the applicant understands and will comply y'
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
�.v ,,:a— i RE-ROOFS:
Signat�nie .r�s� ' '� ' 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
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. 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 Arca 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 25505, 5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: 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 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20777 FARGO DR DATE: 04/22/2015 REVIEWED BY: SEAN
APN: BP#: "VALUATION: 1$3,100
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS
WORK INSTALLATION OF PROPERTY LINE CLEAN OUT.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1 PRSEWER 1 # $25
TOTALS: $25.00
;Meth.flan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Atech, Perinil Fere: Plumb.Permit Fee: 1PPERMIT lslec. Permit Fee:
Other;t tech.Inst. Other Plumb Insp. 0.0 hrs $48.00 Other Elec.Insp. Li
Alech.Insp.fee: Phenib. Insp. Fee: like.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Thesefees are based on the prelimina information available and are only an estimate Contact the De t or addn'l in o.
FEE ITEMS(Fee Resolution 11-053 Lff 7/1/131 FEE QTY/FEE MISC ITEMS
Plan Check Fite:
Sgpj)1. .P(.-1 Fee
PME Plan Check: $0.00
Pertnit Fee:
Suppl. Insp Fee
PME Unit Fee: $25.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning Fees.-
Travel
ees:Travel Documentation Fee: ITRAVDOC $48.00
Stroniz 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: 04/01/2015
7
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 MISC
I 91 (408) 777-3228• FAX(408)777-3333•buildinp(cDcupertino.org
CUPERTINO I
LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN# D
OWNERNAME ` PHONE E-MAIL
STREET ADDRESS h CITY, STATE,ZIP FAX
C� _uN
CONTACT NAMEPHONE E-MAIL
LP _ Dfl/ �/G —V 7—
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME J1V LICENSE NUMBER/° LICENSETYPEC 3r BUS.LIC#
COMPANY NAME , E-MAIL FAX
STREET ADDRESS /f/� // CITY,SSTATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC 4
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF I FD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN El YES I5 THE BLDG AN ❑YES
BUILDING: COMMERCIAL URBAN INTERFACE AREA jV0 FLOOD ZONE r` 0 EICHLER ROME? O
DESCRIPTION OF WORK
TOTAL VALUATION: 1��V RECEIVED BY` x at x ' r k
By my signature below,I certify to each of the following: I am the property owner or authorized agent 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 buil i g conction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
'SUPIKRUENTAL INFORMATION REQUIRED
OFFICEUSDiO�VLYtit;. a {,
o1,�S:•�/l C/f)° Cl�J� G 01'
t'
M owl
t OVER THE COUNTER "
n
U Yid _ w
4 MATORk
MEPMiscApp_2011.doc revised 06/21/11