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15060144 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10679 FARALLONE DR CONTRACTOR:TATS INC DBA MR PERMIT NO: 15060144 ROOTER PLUMBING OWNER'S NAME: ROBINSON RICHARD C AND KATHLEEN A T 2827 AIELLO DR DATE ISSUED:06/22/2015 O 'S PHONE: SAN JOSE,CA 95111 PHONE NO:(408)227-1630 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL 3 REPLACE 4" SEWER LINE FROM CLEANOUT TO License Class Lic.# IM l V� PROPERTY Contractor [/�j/� ��� Date 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5882 / I have and will maintain Worker's Compensation Insurance,as provided for by L Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36935007.00 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 D FROM LAST CALLED INS PZT�' indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date G(( 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 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) 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,Sections 25505,25533,a d 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 ._..__.........._..._......._.. GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408)777-3333 • buildina(c.cupertino.org MISC -]PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN#ell OWNERNAME 0 PHONE E-MAIL I C kol)�CJ Rob,[ STREET ADDRESS 7 vu( r 6 In CITY, STATE,ZIP c r I T\0 a c CONTACT NAME PHON _ � E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑ OMWER ❑ O"A NER-BUII-DER ❑ OWNER AGENT ❑ CONMACTOR ❑CONTRACTOR AGENT ❑.ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TE_NAN r CONTRACTOR NAME f LICENSE NUMBER C LICENSE TYPE BUS.LIC 4 _ COMPANY NAME [1 E-MAIL FAX STREET ADDRESS Z� Q CITY,STATE,ZIP PHONQ ` 1 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC COMPANY NAME E-MAIL. FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAT Y PROJECT LN WILDLAND ❑ YES PROTECT IN ❑ YES IS THE BLDG AN ❑ YES BI=LNG: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO DESCRIPTION OF WORKaAQC_a� o e C,IIOU VAOU-�� TOTAL VALUATION: �yy EIVEDB �`�- By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pr perty 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 building co ;traction. I autho ' e representatives of Cupertino to enter the above-identified pr pertry for inspection purposes. Sig-nature of ApplicantiAgent: �� �,%y� � Date: /Z L�l J SU-PPLEMENTAL IINIFORvIATION REQUIRED ' OVER, HE COU77 '� ER , l h IN, AIEPAfiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION 15060) L�t ADDRESS: 10679 Farallone Dr DATE: 06/22/2015 REVIEWED BY: Paul APN: 369 35 007 BP#: EVALUATION: $5,882 — j 'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 RPS WORK Replace 4" sewer line from cleanout to property SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $25 TOTALS: -7 $25.00 Plumb.Plan Check 0.0hrs $0.00 -T tlec/r. 11etv„rt£L, Plumb. Permit Fee: IPPERMIT , !:- Other;1/ech. Insp. Other Plumb Insp. 0.0 hrs $48.00 Other Elec.Insp. —j t-l�cla. /rasp. F'(- phind). hasp. he= /;Iec.hasp. Pipe: 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 Eff: 71/13) FEE QTY/FEE MISC ITEMS 'an Check Pee: Suppl. PC Fee PME Plan Check: $0.00 '�rmil.Fee. "?r1�p1. Iresrr I'ee PME Unit Fee: $25.00 PME Permit Fee: $48.00 Administrative Fee: ]ADMIN $45.00 Work Without Permit? © Yes (j) No $0.00 Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.76 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $167.76 $0.00 TOTAL FEE: $167.76 Revised: 05/07/2015