15100235CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10820 SANTA TERESA DR I C"NTRACT012- 4::7 J, PI Um �- ^,� PERMIT NO: 15100235
I OWNER'S NAME: JANET M VERSON I I DATE ISSUED: 10/29/2015 1
I OWNER'S PHONE: 4082420054 1, 1 PHONE NO: I
LICENSED CONTRACTOR'S DECLARATION
License Class C— 3 � Lic. # g . b-7
Contractor 1 Date
I hereby affirm that I am licensed Vnder 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:
t. I have and will maintain a certificate of consent to self -insure for Worker's
n, as provided for by Section 3700 of the Labor Code, for the
of the work for which this permit is issued.
I� 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
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 s c regulations er th Cupertino Municipal !Code, Section 9.18.
Signature �7 �-�Date
u
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1 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 offer or
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed co
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
t. 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 SEWER LINE BETWEEN FOUNDATION AND PROPERTY
LINE;lJA&TALJ, 2 -CN) j:,(AC4VlCt,,L �S QS roqu I r2o�
b!� code,
Sq. Ft Floor Area: I Valuation: $5600
APN Number: 35613013.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date: 10 7-0(1
R ROOFS:
All roofs shall be inspected prior to any offing material being installed. If a roof is
installed without first obtaining an inspeon, I agree to remove all new materials for
inspection. �
Signature of A
COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
'IINOkirread the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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, Sectipd#15505, 25533, and 25534.
Date: /C)— L C2 — ( -
I hereby affirm that tt#fe 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
. - '- P%
- -.- GENERAL PERMH i APPLICATION
MEV
COMMUNITY DEVELOPI,/�ENT DEPARTMENT - BUILDING DIVISION
'. 10300 T ORRE AVENUE - CUPERTINO, CA 55014-3255
(408) 777-3228 - FAX (408) 777-3333 - bui1dlno(0-)CUDeriino.Orq
C:UPERTI!-t0 l l5 (00235
PLUTQBING ❑MECFLANICAL ❑ET ECTRiC?? ❑1,4ISCELLANEOUS
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CITY, STATE, ZIP
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❑ OFm ❑ OWI.rmauiDP?t ❑ OW>`-rmAGENT CO\7RACTOR 0C0.17RACTOR.AGENT ❑ ARCFSECT ❑ DvGWB-ER ❑ DEVELOPER ❑ T---, Tr
CONTRACTOR KIkKEE JF i
I LICENSE N 4BER
I LITE TYPE
BUS. LIC
COMPANY NAI r✓E E-MAIL I
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FAX
STREET ADDRESS C1W, fT.ATE, ZIP
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I PHONE
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A RCHITECT/ENGMER NAME I LICENSE XMfIBER
I BUS. LIC n
COMPA.NYMAME
E-MAIL
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STREET ADDRESS
CITY, STATE, ZI?
PHONE
USE OF ❑ SFD or DGPLEX ❑ MULTI-FAhaLY I PROMECT IN WI DLAND ❑ )—s
BUIIDP.G: ❑ COMJ mCLA? LJRBPN LNr=ACE AREA ❑ :ac
PROTECT IN ❑ YFS
FLOOD ZONE ❑ NO
I IS TIL BLDG AN ❑ _s
MCHLER HOME? ❑ NO
DESCPdIPTION OF WORK
� I L
TOTAL VALUATION:,C cCcI Dnp
By my signature below, I certify to each of the following: I arm the property owner or authorized agent to act on the property owner's 8.tr f. 1 have read this
application and the information I have provided is correct. I have rea the Description of Work and verify it is accurate. I agree to comply Avith all applicable local
ordinances and state laws relating to b � ' g co ction. I au a representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: (> Z 1= ( S
SU-PPLEhIENTAL SFORKIATION REQUIRED
A'fEPA-fiscAPP_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 10820 Santa Teresa Dr
DATE: 10/29/2015
REVIEWED BY: Phuong
UNITS
APN: 356-13-013
BP#:
*VALUATION: 1$5,600
-°PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPSS
I PERMIT TYPE:
WORK
Re lace sewer line between foundation and property line E property cleanout to remain.
SCOPE
' zIfppl. irls'p Fec
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Sewer, Sanitary
1 PRSEWER
01her I.lec. Insp.
1
#
$25
Pernv/ Fee.
' zIfppl. irls'p Fec
F71
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
onstruclion Tax.-
ax:Administrative
AdministrativeFee: 1ADMIN
$45.00
Work Without Permit? O Yes 0 No
$0.00
TOTALS:
7
i
Travel Documentation Fee: ITRA VDOC
$25.00
Strong Motion Fee: 1BSEISMICR
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 preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-033 Eff. 711/13
11ech. Plan Check
-5,
Plumb. Plan Check 0.0 1 hrs $0.00
I7ec. Plaii Check
F1, Perrnil i,
Plumb. Permit Fee: IPPERMIT
7rher tech. Insp.
Other Plumb Insp. 0.0 hrs $48.00
01her I.lec. Insp.
k>ch. Insp. Fee'
lamb. Insp. Fec
1"'Iea Imp. Fee -
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 preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-033 Eff. 711/13
FEEQTY/FEE
MISC ITEMS
I'hin Check Fee:
;S`uppl. PC Fee
PME Plan Check:
$0.00
Pernv/ Fee.
' zIfppl. irls'p Fec
F71
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
onstruclion Tax.-
ax:Administrative
AdministrativeFee: 1ADMIN
$45.00
Work Without Permit? O Yes 0 No
$0.00
Idvaneed Planning Fees:
i
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: 1BSEISMICR
$0.73
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$167.73
$0.00 TOTAL FEE:
$167.73
Revised: 10/01/2015