15100084I CITY OF CUPERTINO BUILDING PERMIT I
I BUILDING ADDRESS: 851 BETTE AVE I CONTRACTOR:
PLUMBING S INC DBA MR I PERMIT NO: 15100084 I
OWNER'S NAME: SHUKLA MAULIK ANP ROOPA 12827 AIELLO DR I DATE ISSUED: 10/12/2015
OWNER'S PHONE: 4082210891 1 SAN JOSE, CA 95111 1 PHONE NO: (408) 227-1630
J' LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # R(,% 7 �-
Contractor %-,S n e- Date 1,0
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:
1. 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.
. 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
permit is issued.
APPLICANT CERTIFICATION
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 sav
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the .000
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
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
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
permit is issued.
3. 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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
APPLICANT CERTIFICATION
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
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
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REPLACE (E) SEWER LINE FROM FOUNDATION TO PROPERTY
LINE & INSTALL 2 (N) CLEANOUTS
Rr
Sq. Ft Floor Area: I Valuation: $4000
APN Number: 36927042.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS ALLED INSPECTION.
Date: / Z
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner apauthorized agent:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
GENERAL PERMIT APPLICATION lmlvml E
COMPJiUNiTY DEVELOPMi�ENT DEPARTMENT - BUILDING DIVISION
10300 T ORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - _buildina(d)-cuoertino.org _ O
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STREET ADDRESS 6 2, -?,c ,C I C11 T TV N z I
CONTACT NAVE� PH 'E f—wE-?.ZAII.
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STREET AMDRESS CITY, STATE, ZIP FA X
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A-RCETECT/ENGL',�-EERNAME
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USE OF ❑ SFD or DUPLEX ❑ MULTI -F °.,OILY I . PROJECT IN wII-DL�TD ❑ .S PRO7ECT N ❑ YES
B'=\'G: ❑ CO,=CLA_T URB N L=ACE ARF- ❑ NO I FLOOD ZMNH ❑ NO
IS THE BLDG AN ❑ Y is
I EI0MER HOME! ❑ No
DESCP.IPTION OF WORK
TOTAL VALUATION: 3 ^
By my signature below, I certify to each of the following: I am the property owner or authorized agent L on th ope.-ty OWD a f. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it iscurat o comply with all applicable local
ordinances and state laws relating to building con ction. I authorize represpllff>s of Cupertino to enter thea enti Sed property for inspection purposes.
Si�rnatare of Applicant/Agent:
SU-PPLEMENTAI, LNFORMATION REQUIRED
I17EPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 851 BETTE AVE DATE: 10/12/2015 REVIEWED BY: MELISSA
NJ oil APN: 369 27 042 BP#: *VALUATION: 1$4,000 I
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPS
USE: PERMIT TYPE:
WORK REPLACE (E) SEWER LINE FROM FOUNDATION TO PROPERTY LINE & INSTALL 2 (N)
SCOPE CLEANOUTS
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 1 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
T'k-!c, Permit Fee:
Sewer, Sanitary A
1 PRSEWER
Other I-Jec. Insp.
1
#
$25
I)errnit P 'ee.-
SuppL Insp Fec
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
F
Administrative Fee: JADMIN
$45.00
Work Without Permit? Yes (j) No
$0.00
TOTALS:
'A
Travel Documentation Fee: I TRA VDOC
$25.00
Strong Motion Fee: IBSEISMICR
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
I)ivtr;rt- Ptr-)- Thorn foov arp havod an tho nnoliminary infnrmatinn availahip and am only an Pvfimatp- Cnntart thp Dent fnr addn'l info_
FEEITEMS (Fee Resolution 11-053 Eff. 7/1/13,
Alech'.1,1(m
Plumb. Plan Check 1 0.0 1 hrs $0.00
i ec, Nan Check
Peck Permit Fee:
Plumb. Permit Fee: IPPERMIT
T'k-!c, Permit Fee:
Other .,,-Uech. Am]).
Other Plumb Insp. 0.0 hrs $48.00
Other I-Jec. Insp.
Afech, h?ml 11''e:
PME Plan Check:
$0.00
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
I)ivtr;rt- Ptr-)- Thorn foov arp havod an tho nnoliminary infnrmatinn availahip and am only an Pvfimatp- Cnntart thp Dent fnr addn'l info_
FEEITEMS (Fee Resolution 11-053 Eff. 7/1/13,
FEE
QTY/FEE
MISC ITEMS
Phin Check Fee:
1, "! Z'/ ) 1, P( ,, Cc
F
PME Plan Check:
$0.00
I)errnit P 'ee.-
SuppL Insp Fec
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
F
Administrative Fee: JADMIN
$45.00
Work Without Permit? Yes (j) No
$0.00
'A
Travel Documentation Fee: I TRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.52
Select an Administrative Item
1
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS: 1
$167.521
$0.00 TOTAL FEE:
1 $167.52
Revised: 10/01/2015