15120016U
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1103 MILKY WAY
CONTRACTOR: SAN JOSE PLUMBING
PERMIT NO: 15120016
INC
OWNER'S NAME: NEILSON BARBARA G TRUSTEE
19970 MCKEAN RD
DATE ISSUED: 12/02/2015
OWNER'S PHONE: 4088575976
SAN JOSE, CA 95120
PHONE NO: (408)296-1820
0� LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑
INSTALL (N) PROPERTY LINE CLEANOUT AND REPLACE
License Class c'- 3 Lie. # / / %
30'
Contractor S . ,) �Sp fc7w„L 1,.? � Date U Z- -- l
OF SEWER LINE "CUPERTINO SANITARY"
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
Sq. Ft Floor Area:
Valuation: $4850
performance of the work for which this permit is issued.
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: 36219009.00
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 D YS FROM LAST CALLED INSPE TI N.
indemnify and keep harmless the City Cupertino against liabilities, judgments,
`7 (p r
costs, and expenses which may accrue against said City in consequence of the
a
� jL(, �
1 W� .� �J OCI.JY(
Issued by: Date:
granting of this permit. Ad tionally, the applicant understands and will comply
with all non-poi9ko ire e lations p the Cupertino Municipal Code, Section
9.18. F.
(71 — 1
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 DECLARATION
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 Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectipps 2 505, 255 , and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date: �•— Z — f�
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
9.18.
Signature Date
GENERAL PERMIT APPLICATION OlaMl& .
COMMUNITY DEVELOPMiENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 9501A-3255
(408) 777-3228 • FAX (408) 777-3333 • buildina(a)cuoerJnc.org
PLLJh G ❑]'ECI A-MC.kL, ❑rLECTPICA.L ❑AHSCELLAKEPOUS
PROTECT ADDP.ESSf
I APN - � /1' 0 [ q
I i
L10
cm,
OW1 rRN�1JE
I I
PrI01;E
(4m
�.
E-1J1IL
STREET A .DDRESS
CITY, STATE, ZIP
FAX
113 �.
CONTACT N.�JE
PHO
E-MAII
STREETA.DDP.ESS
CITY, STATE, ZIP
FAX
❑ OFR\=R ❑ OtiR\ER-3Ui D=R
❑ OR'?.�tAGE.T
❑ CO? TP.kc-rOR ❑ CONFFRACTORAGE? T ❑ ARC=:ITECT ❑ E GL\—=R ❑ DEVELOPER ❑ i_1;,,.x-r
CONTRACTOR MI
I LICENSE 1\'UbMER
I LIC-nSE TYPE
I BUS. LIC
COWA1 Y NAIL
E-NAZ
ISwL
l
SanC
105e (j
MA C I h 1 o• CULL 1
STREET A Tom' DRESS
CITY, STATE, ZIP
PHONE
1 r�
Mc kect
�,
tee. r� ��
L —1 gZ'v
ARCEITECT EnGLKEER NAME
I LICENtF N'U3,0ER
BUS. LIC
COMMNY NAIVE
E-ML"M
FA-
STREET ADDRESS
CITY, STATE, ZIP
I PHO1�i
USE OF ❑ SFD or DUPLEX
❑ MjLTI-FAhffi.Y
PROTECT LN' WILD LAND ❑ YF -S
PROI--QCT LN ❑ YES
IS T- = BLDG AN ❑ Y':S
BUIIDN''G:❑COhC,E-PCLA?
LT Z3AN, PTERFACEAREk ❑ NO
FLOOD ZONE ❑ NO
I EICF=HOME? ❑ NO
DESCRIPTION OF WORK
,
it
C&ut
_ 0 14
0 -FK 4q
O
i
TOTALVA-LUATIO?�:.
v RLCFI; D�1 L rt
.„t
By my signature below, I certify to each of the following:
Ism, the grope• ty owner or authorized
zsent to act on the property owner's behalf. I have read this
application and the L-afornation I havA
pro; ed is correc
have read the Description of 'Work
and verify it is accurate. I agree to comply with all applicable local
crcinances and state lz;; s relztLg
"d' Q construe` o
au' -e representatives of Cupertino to enter the above-identiued property for inspec ion purposes.
Signature ofA.pplicpn /^-.gent
Date:
SLPP EME iTAIL\'FORvATION REQUIRED
0
ORFSCE{LSE ONLI��
w,oti'E3 THE CO1j TER .
, 1
:C4RUE
t Q
v �
1/EPh'isc4vp_2011.doc revised 06/21/11
CITY OF CUPERTINO -1519W[b-
FEF ESTIMATOR — 131JILDING DIVISION
ADDRESS: 1103 Milky Way
Plumb. Plan Check 0.0 1 hrs $0.00
DATE: 12/02/2015
REVIEWED BY: PAUL
Plumb. Permit Fee: IPPERMIT
APN: 362 19 009 -
I BP#:
Other Plumb Insp. 0.0 hrs $48-00
*VALUATION: 1$4,850
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
$0.00
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
Install (N) property line cleanout and replace
30' of sewer line "Cupertino Sanitary"
SCOPE
APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $25
J -
Sewer, Building 1PRSEWER 1 # $25
TOTALS: $50.00
VOTE. 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 aaan -i info.
FEE ITEMS (Fee Resolution 11-053 Aff.71�1113
Plumb. Plan Check 0.0 1 hrs $0.00
flan
MISC ITEMS
Plumb. Permit Fee: IPPERMIT
Petvi,4•s Fee:
Other Plumb Insp. 0.0 hrs $48-00
h,.,sp. Fee:
VOTE. 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 aaan -i info.
FEE ITEMS (Fee Resolution 11-053 Aff.71�1113
FEE
QTY/FEE
MISC ITEMS
Plan Check.l."ee:
SuppL PC.Fee
PME Plan Check:
$0.00
permil]"ee:
ksupj-/, hlSal .Fee
F71
PNM Unit Fee:
$50.00
PNM Permit Fee:
$48.00
Cons!�,vcfio.n 7*��x:
Administrative Fee: (ADMIN
$45.00
Work Without Permit? 0 Yes (D No
$0.00
--
Travel Documentation Fee: I TRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.63
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
'0 TALS,.]
$192.63
$0.00
RPvi.qt-r1-771-ig s