15100167CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18824 TUGGLE AVE
OWNER'S NAME: WILLIAMS SUZANNE ELANE TRUSTEE
CONTRACTOR:' PERMIT NO: 15100167
C -I o l4 wn t?( -4-4 t
DATE ISSUED: 10/21/2015
OWNER'S PHONE: 5628822172 1 , 1 PHONE NO:
m LICENSED CONTRACTOR'S DECLARATION
License Class
+ " C -?� & Lie. % O 9-
Contractor "-to-S ") K t"10'1�z Date /� )-2— / t '• I
(
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. 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. 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 save G
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 reg ions per the Cupertino Municipal Code, Secti 9.18.
Signature C Date
❑ OWNER -BUILDER DECLARATION
1 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:
i. 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. 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.
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 & INSTALL FOUNDATION &
PROPERTY LINE CLEANOUTS (SUNNYVALE SANITARY)
Sq. Ft Floor Area: I Valuation: $6000
APN Number: 37532029.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DA
INSPECTION.
RE -ROOFS:
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.
Owe or au ized nogg t: /l
Date• i
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
m GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPIdiENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 85014-3255
(408) 777-3228 •FAX (408) 777-3333 • buildina(ftuoertino.orcl
CUPERI`[h1Q ` l -m
7hLUMBING El MECHANICAL ❑ELECTRICAL ❑MilSCELLANE0US
PROJECT ADDRESS Y g Z / T 1e * ✓ e I APN ; �1 _ 2
01'1�IR NAME U Z ci L.,2 W 1 I I!tPHSONE ) OR Z-Z 112
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LICENSE NUMBER
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CITY, STATE, ZIP
PHONT-
USE OF ❑ S, -D or DUPLEX ❑ IvfULTI-F.A ,CLY PROJECT LN WI DLA M ❑ ]—.s
BU N10: ❑ COMMERCIAL URBA--, INTERFACE AREA NO
PROJECT IN ❑ YES
I FLOOD ZOITE ❑ NO
IS THE BLDG AN ❑ YES
I EICFMER HOME? ❑ NO
D SCRIPTION OF WORK
a e c e w Q t� v _ K c:� �� 1� - J- o e►—f- J �� if 'q
TOTAL VALUATION:
By my signature below, I certify to each of the following: I am the property ov or authorized aggl5t to the y u —Ly owner's behalf. I have read this
application and the infonnation 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 c nst mctio authorize representatives of Cupertino to enter the above -id ntified p perty for inspection purposes.
/151/ -2—
Sig;nziure of Applicant/Agent:Date:
SL-PPLEhfENTAL INTF'ORMATIONT REQUIRED
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ATFPMisc.4pp_2011.doc revised 06121/11
WE
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 18824 tuggle ave --7DATE:
10/21/2015
REVIEWED BY: MELISSA
UNITS
APN: 375 32 029
BP#:
'VALUATION: 1$6,000
xPERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPS
PERMIT TYPE:
WORK
REPLACE E SEWER LINE & INSTALL FOUNDATION & PROPERTY LINE CLEANOUTS
SCOPE
(SUNNYVALE SANITARY)
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Llec. Permit �'c�e
Sewer, Sanitary
1 PRSEWER
:)t/ter i1lec. Insp.
L—J
1
#
$25
Permit Fee:
S7'q'y1 110P 1,1'1
F
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: IADMIN
$45.00
Work Without Permit? Yes E) No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRA 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
District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
Meth. Plan Check
Plumb. Plan Check 0.0 1 hrs $0.00
Elec. Plan Check
atc>ch .;
Plumb. Permit Fee: IPPERMIT
Llec. Permit �'c�e
Other :Vech. Insp.F-1 —L—
Other Plumb Insp. 0.0 hrs $48.00
:)t/ter i1lec. Insp.
L—J
;Tech. Insp. Fee
Phanh h:,tip. Tec'
lec. Insp. hee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
.tiuppl. PC Fee
PME Plan Check:
$0.00
Permit Fee:
S7'q'y1 110P 1,1'1
F
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: IADMIN
$45.00
Work Without Permit? Yes E) No
$0.00
A
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.78
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$167.78
$0.00 TOTAL FEE:
$167.78
Revised: 10/01/2015