15050180 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10382 LAS ONDAS WAY CONTRACTOR:GOGO ROOTER PERMIT NO:15050180
OWNER'S NAME: ROBERT MIZERAK 2530 BERRYESSA RD STE 509 DATE ISSUED:05/29/2015
OWNER'S PHONE: 4084380217 SAN JOSE,CA 95132 PHONE NO:(408)282-7026
1 Mar-___
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E]
REPLACE 2(E)WATER CLOSETS&A PORTION OF THE
License ClassLic.#_" N 2 6 BUILDING DRAIN
Contractor SR?
Sc) &MRA 51Date �/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
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:$5500
V ' 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:36928036.00 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 DAYS ST LED INSPECT ON.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, /
costs,and expenses which may accrue against said City in consequence of the ?ifs
granting of this permit. Additionally,the applicant understands and will comply a e a '
with all non-point a regulations per the Cupertino Municipal Code,Section
918.
RE-ROOFS:
Signature Date ��f�A 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 DEC TION
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 Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cup Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 50 5533,an 25534.
Section 3700 of the Labor Code,for the performance of the work for which this — S� G/
Owner or authorized agent: "S'L2 gam. 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
918.
Signature Date
._..........._.........................
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPtRRT[NC7 (408)777-3228• FAX(408)777-3333•buildingCwcupertino.org
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS ,ry CAS Olud F}s ('_/1[ APN '3 6 �J v 0
OWI ERNAME (12� f 2 C.._ PHC �� [_. a O Z� ,-- E-MACI�L
STREET ADDRESS /� 3 8-2 CAS �y �S CITY, ST�jA�+TE,ZIPc`Ci
- CA``f F gaff FAX
CONTACT NAMEV TE-MAIL
STREET ADDRESSCIT(,STATE,ZIP FAX
�ZCQ �/�cLa /} S4NAu 1
❑ o)A%,ER ❑ owiTER-BUILDER ❑ OWNERAGENT ❑ CONM' ACTOR ❑ONTRACTORAGINT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME / SSSS Z-9` LICENSE NUMBER ��7 d// LICENSE TYPE C 3� BUS.LIC
COMPANY NAME / S � raj pC, E-MAIL FAX
STREET ADDRESS 324 �4 Lip, 1 CITY,STATE,ZIP L f Gti� CAW 5121 PHONE/ J
G C _Y� V (, EOE
ARCHITECT/ENGMTEER NAME 7 LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHO�B
USE OF Q SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUIIAAG: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE Q NO EICHLER HOME? Q NO
DESCRIPTION OF WORK
TOTAL VALUATION: 5 � y EIVED$] r P.Y wM y �w
By my signature below,I certify to each ofpmflill
lowing: I am the property owner or authorized agent to act on the p ner s behalf. I have read this
application and the information I have avcorrect. 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 build' onstruction I thorize represen Ives of Cupertino to enter the above-identified pro erty for inspection purposes.
Si�paature of Applicant/Agent: ' �— r/� „ Date:
IPPLEMENTAL INFORMATION REQUIREDorcE usEo,Li '
;'.q
�� ; ,
ON
��05ER TBE COULTER
�g RXPRESr4 3 �� �'
x � xu � •
L4RGE � ' s
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10382 LAS ONDAS WAY DATE: 05/29/2015 REVIEWED BY: MELISSA
APN: 369 28 036 BP#: I 'VALUATION: 1$5,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1RPFIX
USE: I PERMIT TYPE:
WORK REPLACE 2 E WATER CLOSETS &A PORTION OF THE BUILDING DRAIN
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixture set on One Trap 1 BPFIXTURE 2 # $20
Sewer, Building 1 PRSEWER 1 # $25
TOTALS: 1 $45.00
ltech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 El,,.Plan Check
b9eclr. Permit five: Plumb.Permit Fee: ]PPERMIT illec. Permir Fee:
Other rt/ecdr. Insp. Other Plumb Insp. 0.0 hrs $48.00 Other E'lec.Insp. El
idech.117sp.Fee: 11hnrau. hup. 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.). These ees are based on the relimina in ormation available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E f 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Per•init Fee:
S1+1-21)1. I77SP Fee
PME Unit Fee: $45.00
PME Permit Fee: T-T $48.00
Construction Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITR,4VDOC $48.00
Strong Motion Fee: IBSEISMICR $0.72 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS:? $187.72 $0.00 TOTAL FEE: $187.72
Revised: 05/07/2015