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15060197 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22346 MCCLELLAN RD CONTRACTOR:TRENCHFREE INC PERMIT NO: 15060197 OWNER'S NAME: THUY LAM PO BOX U DATE ISSUED:06/30/2015 OWNER'S PHONE: 4089216692 SAN JOSE,CA 95151 PHONE NO:(408)726-7926 Y LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑ / INSTALL(N)PROPERTY LINE CLEANOUT License Class�3� (Z Lic.# "n(,:VollO Contractor J(61Gh Z/1G Date Ll 90 A 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 S Y Code and that my license is in full force and effect. AN TAR 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:$3000 7� 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:35705062.00 O«up,incF l)Pe: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WIT AYS 0 T 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 0 AS D INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgm , costs,and expenses which may accrue against said City in consequence of the 3 granting of this permit. Additionally,the applicant understands and will comply ss by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature ., �/' Date t7 ! ]iin�spectio ll roofs shall be inspected prior t eing installed.If a roof is stalled without fir n inspection emove all new materials for ❑ OWNER-BUILDER DECLARATION Signature o icant: 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) 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,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: a nl^ Date: L✓�d 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 MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333 • buildina(a)cupertino.org / CUPERI'tNU / S Q 60 Isc / ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ((❑MISCELLANEOUS PROJECT ADDRESS iv �) ,, nUAPN n ? _ O /� _ OWNER NAME 1 �M PHONE L E MAIL j STREET ADDRESS n -Z,3• /I Ii;, CITY, STATE,ZIP Q (�y111. FAX Joe CONTACT NAME /'ar O; IInr PHONE 14" E ��l' r��i- ree � v STREET ADDRESS I�„��0 tirL CITY,S�E, ZIP �+ n ^� `-f i FAX ❑ owR,,ER ❑ OV7N'ER-BUII.DER ❑ OWNER AGENT Dd CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGLKEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME /��n IO S LICENSE NUMBER LIC 'SF,,TYPE 7 BUS.LIC COMPANY NAME n�� �n`. EMAIL STREET ADDRESSuAtM� CITY,STATE,Z K _An �(,�' •` /I� �� P11 E ARCHITECT/ENGINEER NAME (�lJ (— LICENSE NUMBER (/� BUS.LIC R COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO DESCRIPTIONOF WORK -A X11OL M 44- P()0 kr, .I^G -Otlt TOTAL VALUATION: -7)00 U RECEI re' } By my signature below,I certify to each of the following: I am the property owner or authorized age to act on the prop e ner'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 construction. I authorize representatives of Cupertino to enter the above-identified L� property ffor ainspection purposes. Signature of Applicant/Agent: Date: lJ I J Q ! J SUPPLEMENTAL INTORMATION REQUIRED Q' �. OFFICE USE OALI v3 ., R THE COUNTER V y ' a'$K I 111 '00 £JO'RES$ ❑ �. A7EPMiscApp_2011.doe revised 06/21/11 CITY OF CUPERTINO 12 FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 22346 MCCLELLAN RD DATE: 06/30/2015 REVIEWED BY: MELISSA APN: 357 05 062 BP#: © -VALUATION: $3,000 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: p PERMIT TYPE: WORK INSTALL N PROPERTY LINE CLEANOUT SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $25 TOTALS: $25.00 7_1 Plumb.Plan Check 0.0 hrs $0.00 laec.Plan CheckI I lteiar. I'erntit Fix Plumb.Permit Fee: IPPERMIT Islec. P<rmil kee Other Uech.Insp. Other Plumb Insp. 0.0 hrs $48.00 Other Llec.Insp. 1lech, Insp. Fee: Phtmtr. hrsp. FCC Glec. 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. . Theseees are based on the relimina information available and are onlyan estimate. Contact the Det or addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef` 7/1/131 FEE QTY/FEE MISC ITEMS "lan Check Pee: S'uppl. .PC'Fee PME Plan Check: $0.00 rmit Fee: Suppl. Insp F''-' PME Unit Fee: $25.00 PME Permit Fee: $48.00 "!nstruction Tll:r: Administrative Fee: ]ADMIN $45.00 Work Without Permit? Yes (F) No $0.00 ?,,Ivanced Planning Fees. Travel Documentation Fee: ITRA VDOC $48.00 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