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15110129l CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10264 JUDY AVE CONTRACTOR: ABLE SEPTIC PERMIT NO: 15110129 OWNER'S NAME: BARBARA J FAULKNER 1020 RUFF DR DATE ISSUED: 11/18/2015 OWNER'S PHONE: 4082523323 SAN JOSE, CA 95110 PHONE NO: (408)377-9990 LICENSED CONTRACTOR'S DECLARATION 0 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL REPLACE (E) PROPERTY LINE CLEANOUT AND REPLACE - License Class Lia# 10' v e_� � OF SEWER LINE **SUNNYVALE SANITARY** Contractor Date /�/f IT -- l 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: $3750 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: 37510013.00 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 DAYS FROM LAST CALLED INSPECT N. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the L®k6wl j �� granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: ll �S with all non-point source regulations per the Cupertino Municipal Code, Section RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is 9.18. � Signa ure Date 'J 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, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this ; — 1 L /.S permit is issued. Owner or authorized age .� Date: — �— 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 CUPERTINO. GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPART NiENT • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014 3255 (408) 777-3228 • FAX (408) 777-3333 • bui1dino5cuoei ino.org n)zq. ME P PLUA43RNG ❑hECNAl`IC.AI, ❑ELECTRIC.- ❑),,ISCELL,4_1,�,OUS PROJECT. DP.ESe I .! N431� U �I •-�— v-100._JL CITY, STATE, Zip I FAX \ CONTACT N.4 -1,62,E � PHONE � o ELy Q Y e1 � � 9 ST FET a.DDP/`S I CITY, STATE, Zip ❑ ❑ ow2,T,-B=ER ❑ ❑ CO?7?ACTOR ❑ CO\?J,CTOR.4G?�T ❑ -?'CT ❑ —=NGL"Z---R ❑ ❑ :SRC DEFVEELOPE—� 1_1,,e,N7 CO'-RACTORNaI,r� r, \ I LI E?�SE?ZI ER I LICENSEi�,rPE ,� I B'S.LIC 1 CONPATY NAIa N4IL p. v 116V-11 et(c a MI o STREET ADDRESS CITY, STATE, Zip P. ONE F_TRCHI TECTrnGI EERN,4NE LICENSE NUMBER BUS. LIC r CON,PANYKk]0. ,E E -M lkm I FAY, STREET ADDRESS I CITY, STATE, ZIP I P O E USE or -[Vs, -D, or DTP=- ❑ N.un-Fhhm-Y I . PROJECT IN WII DLA -ND ❑ YES ?ROTHCT IN ❑ LS IS THE BLDG AN ❑ Y S BuZJr'LNG: ❑Col'O' -RCIAL URBAYIN RFACEA-Pak ❑ 140 FLOODZO'KM ❑ ?v0 EICFLERHO]"'m ❑ NO DESUIPTION OF WORK (S (vi 6; -cu g:, ai TOT.A.L VALUATION: C� REGI D n� s . r Yfiyi z ra z + tix a . By my signature below, I cerify to each of the following: I am the property owner or authorized agent to act on the pr perry owner's behalf. I have read this application and the Lnformation I have provided is correct. I have read the Description of leak and verify it is accurate. I agree to comply with all applicable local ordt-ances and state la`;,s relating to, building constciction. II authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Si-riaure of "pplican /.Agent �"v ` Date: SLPPLEN_ALLNFORvATI0\ REQUIRED N..n. b FOI�SCE LSE ONL>>�� as ; - > Q- TiiE COOL HE Fi s _ �. } ilR M��Sl g m IN qg AIEP.AJ7sc,4pp_2011.doc remised 06121111 CITY OF CUPERTINO I5 Q FFF FNTIMATOR — BUILDING DIVISION . ' ADDRESS: 10264 Judy Ave DATE: 11/18/2015 REVIEWED BY: PAUL Plumb. Permit Fee: IPPERMIT APN: 37510 013 BP#: *VALUATION: $3,750 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Du lex p PME Plan Check: PENTAMATION 1 RPSS USE: I'l ern- ll 1 ee: PERMIT TYPE: WORK Re lace E property line cleanout and Replace 10' of sewer line "Sunnyvale Sanita ** SCOPE PME Unit Fee: Afech. }'?c n ("heck Plumb. Plan Check 10.0 1 hrs $0.00 flan (7he k :Mach-Permii .1 ee; Plumb. Permit Fee: IPPERMIT 1 'isc. 1 etw.-is Fee: Other Plumb Insp. 0.0 hrs $48.00 Clrirt Ziec. lr,, z�. .1kch, 1r„SZJ. Fee: F -e: EIVC:. ir'sp. Fee: : NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Nire, i'anitary Fewer utstrict, 3'cnoot District, etc.. Theseees are based on the preliminar information available and are only an estimate. Contact the Dept -for addn'l info, FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/132 FEE QTY/FEE MISC ITEMS Plan ("heck —! ee, PME Plan Check: $0.00 I'l ern- ll 1 ee: tiS'uppl. In p .l ee PME Unit Fee: $50.00 PME Permit Fee: $48.00 (.,'onsSfY'ucl ion Kix: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (D No $0.00 Advanc&lPhm ing1;L'es: Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS . $192.50 $0.00 , , TOTAL Revised: