15100027 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22434 ST ANDREWS AVE CONTRACTOR:DRAM DOCTOR PERMIT NO: 15100027
OWNER'S NAME: GUITTARD GEORGE V AND RUTH K TRUSTE 480 ALDO AVE DATE ISSUED: 10/05/2015
OWNER'S PHONE: 4082531256 SANTA CLARA,CA 95054 PHONE NO:(408).370-3082
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
� INSTALL(N)PROPERTY LINE CLEANOUT;(N)BUILDING
License Class G GTlLLic.# d v--;��4f S CLEANOUT AND INSTALL 60'OF TRENCHLESS SEWER LINE
r' REPAIR"CUPERTINO SANITARY**
Contractor A4V1 p0l�~ Date / 0-3 - / �r
I hereby affirm that 1 am licensed under the provisions of Chapter 9 SANITARY
(commencing with Section 7000)of Division 3 of the Business&ProfessionsCode and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: Valuation:$8000
t 1 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. P� umber:35603004.00 Occupancy Type:
C1 have and will maintain Worker's Compensation Insurance,as provided for b}
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
PERMIT EXPIRES IF WORK IS NOT STARTED 1 certify that 1 have read this application and state that the above information is WITHIN 180 DAYS OF PERMIT ISSUANCE OR
correct.I agree to comply with all city and county ordinances and state laws relating 180 D YS FROM LAST CALLED INSPECTION.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to savetktL0�ULL-4/)CrJd j plindemnify and keep harmless the City of Cupertino against liabilities,judgments, Issued by: Date: 5,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply with
all non-point source regi4ations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS:
Signature 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 04CLARATION Signature of Applicant: Date:
I hcrel,c affirm that 1 am exempt f m the Contractor's License Law for one of
the lidlo%s iug two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 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 fur HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code). California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
1 hereby affirm under penalty of perjury one of the following three declarations: Safety Code,Section 25532(x)should 1 store or handle hazardous material.
t. I have and will maintain a Certificate of Consent to self-insure for Worker's Additionally,should I use equipment or devices which emit hazardous air
Compensation,as provided for by Section 3700 of the Labor Code,for the contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
2 1 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 Owner or autho ized agen
permit is issued. Date: ,P o-
3,
3. 1 certify that in the performance of the work for which this permit is issued,l shall
not employ any person in any manner so as to become subject to the Worker's CONSTR TION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked.
Lender's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION
correct.1 agree to comply with all city and county ordinances and state laws relating understand my plans shall be used as public records.
to building construction,and hereby authorize representatives of this city to enter
Upon the above mentioned property for inspection purposes.(We)agree to save I icensed Professional
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 with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
/ GENERAL PERMIT APPLICATION ��I�� � E 'r
`� COMMUNITY DEVELOPh4ENT DEPARTMiENT-BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 85014-3255
(408)777-3228 • FAX(408)777-3333• bu1ldin0(a)cuoerJno.or0 iv]CUPERTINO E�
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❑ Ota'E.R ❑ OR1TcR-B1-=ER ❑ O-,.WER AGENT CONTRACTOR ❑CON`7RACTOR AGn'T ❑ ARC?S ECT ❑7-NG1\-E-R ❑ DEl ELOPER ❑ .__.
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STREET ADDRESS vkv ' �✓ e CITY,STATE,ZIP �. y?0\E
ARCHITECT;ENGNEFRN.SI F LICENSE NUb!BER BUS.LIC
COMPANY N.AMME E-MAIL FAY. --
STREET AL-'=SS — CTTY,STATE,ZIP PHOKE --
_ ❑SFD.,DL?LDC ❑ IJ.LiL7i-F.A.),0LY PROJECT Pv ❑ M PROTECT IN ❑YES IS TKE BLDG.w ❑ YES
EL'LTDNG: ❑COl✓C.Ma"L trRBf N INTE ACE AREA ❑ NO FLOOD ZONB- ❑ No EICF1Dt HOWE7 ❑ NO
DESCPaTION CF'�VORK
v, G .SL am d vtt & !8
oY �pvi n II�i1N� Y ��-Q
3y my si parae below,I certify to each of the following: I as the property owner or authorized agent to act on the property owner's behalf. I have read this
zpplication and the information I have provided is correct. I have read the Description of R7ork and verify it is accurate. I agree to comply with all applicable local
c r dinances and state laws relating to building cc ct. n. I autbo ' ti sof Cupertino to enter the above-identified property for inspec ion purposes.
igtatureofApplicanUAgent: Date: / 11 7'y
SUPPLEMENTAL INFORMATION 4 UIRED
AIEPAdiscApp_2011.doc reT,ised 06/21/11
CITY OF CUPERTINO 19- )00030L,
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 22434 St Andrews Ave DATE: 10/05/2015 REVIEWED BY: PAUL
AN: 356 03 004 BP#: 'VALUATION: 1$8,000
-PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
WORK Install N property line cleanout N building cleanout and Install 60' of trenchless sewer line repair
SCOPE "CUPERTINO SANITARY"
APPLIANCE]EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 1 # $25
Sewer, Sanitary 1 PRSEWER 1 # $25
TOTALS: $50.00
Plumb. Plan Check 0.0 hrs $0.00
Plumb. Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hrs $48.00
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 prelindna information available and are only an estimate Contact the De t or addn7 info.
FEE ITEMS (Ice Resolution I1-053 l;l1: 7 1 /3] FEE QTY/FEE MISC ITEMS
'Ian Ch— /, VL
PC L�,�,
PME Plan Check: $0.00
' vuti! 1'rc:
Vp/. 111sp 1-'cc,
PME Unit Fee: $50.00
PME Permit Fee: $48.00
011struclion lax.
Administrative Fee: ]ADMIN $45.00
Work Without Permit? O Yes 0 No $0.00
�,Ivo,u"d P/,,,,;1:,,,. Vr
Travel Documentation Fee: ITRA VDOC $48.00
Strong Motion Fee: IBSEISAIICR $1.04 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $193.04 $0.00 TOTAL FEE: $193.04
Revised: 07/02/2015