15120127CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10631 FARALLONE DR
CONTRACTOR: AMERICAN PERMIT NO: 15120127
RESIDENTIAL SERVICES OF CA
OWNER'S NAME: CAMPBELL BRUCE AND DARLENE M TRUSTE
965 RIDGE LAKE BLVD STE 201 DATE ISSUED: 12/15/2015
OWNER'S PHONE: 4082533664
MEMPHIS, TN 38120 PHONE NO: (408) 982-0405
LICENSED CONTRACTOR'S DECLARATION
01
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E]
REPLACE (E) SECONDARY DRAIN LINE IN CRAWLSPACE
License Class 0,'i,G C-41 R
Contractor 4ILS 4 Q —V� SL 1_(p (26-�tD to 1 S l j
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: $3120
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
APN Number: 36939039.00
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 WORD 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 INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
_
(,j
Issued by: 'l�W ✓�W ' �`� Date:
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. Ar
Signature Date L2 Id,
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.
❑ 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)
1, 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(x) 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, S tions 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date: IT I
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
CUPERTIt-40-
GENERAL PERMIT APPLICATION 15I�OIa�
COMMUNITY DEVELOPIdENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 9501L 3255
(408) 777-3228 • FAX (4-08) 777-3333 • building cuoertino.org
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USE OF W; or DL?L:X
❑ 1J.ULTI-FA1"ZLYI . PROTECT PN' WILDLF STD ❑ YES
PROJECT IN ❑ YES
IS THE BLDG AN ❑ ti =S
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BUMI)NIC: El�'=- .
URBAN' L>\*I�tFACZ APak ❑ NO
FLOOD ZONE ❑ NO
MCFLER.HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION: 2 0 R cCFIS`FDB1Tf
s' x.j41tr K
By my sigaatw-e below, I ce: ify to each of the following: I am the -orop---,Ly prop---,LOwner or authorized agent to act on therope. ty owner's behalf. I have read this
application and h--i*ifornation 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 construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signal"U'reofA.pplicant/Agent: Date: %n, / / j ( 1 S
SU-PPLEhfiENTAL I\TFORvIATION REQULRED
,�4=h!iscApp_2011.doc revised 06/21/11
���.�, ate.
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10631 Farallone Dr
FEE ID
DATE: 12/15/2015
REVIEWED BY: Paul
APN: 369 39 039
1 BP#:
*VALUATION: 1$3,120
'--PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
$25
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
Replace (E) secondary drain line in Crawls
ace
SCOPE
Plumb. Permit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Sewer, Building A
1 PRSEWER
0.0
1
#
$25
pe?wlil
.Vec' per�'W4 Fee:
Plumb. Permit Fee:
]PPERMIT
PME Unit Fee:
$25.00
PME Permit Fee:
F-1
Other Plumb Insp.
El
hrs
$48-00
Lj
$0.00
TOTALS:
lmv� fi"nz':
$25.00
Elec. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Hire, Sanitary Sewer District, School
n-4-;' n#n 'rf.... inns —h—d—th" rmitart the DPW fnr addn'l info.
FEE ITEMS (1,ec Resolution .1.1-053 Lff 7/1/13)
FEE
QTY/FEE
MISC ITEMS
1"kin ("heckb`ee:
snppn' P(.' y fi`et?
Plumb. Plan Check
0.0
hrs
$0.00
$0.00
pe?wlil
.Vec' per�'W4 Fee:
Plumb. Permit Fee:
]PPERMIT
PME Unit Fee:
$25.00
PME Permit Fee:
F-1
Other Plumb Insp.
El
hrs
$48-00
Lj
$0.00
lmv� fi"nz':
$48.00
Elec. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Hire, Sanitary Sewer District, School
n-4-;' n#n 'rf.... inns —h—d—th" rmitart the DPW fnr addn'l info.
FEE ITEMS (1,ec Resolution .1.1-053 Lff 7/1/13)
FEE
QTY/FEE
MISC ITEMS
1"kin ("heckb`ee:
snppn' P(.' y fi`et?
-
I
PME Plan Check:
$0.00
pe?wlil
PME Unit Fee:
$25.00
PME Permit Fee:
$48.00
Administrative Fee: (ADMIN
$45.00
Work Without Permit? 0 Yes G) No
$0.00
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.001
: SUBTOTALS
$167.501
$0.00 TOTALFE.
$167.50
Revised: 10/01/2015