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15120163CITE' OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10776 W ESTATES DR CONTRACTOR: OVERMILLER INC DBA PERMIT NO: 15120163 ROTOROOTER OWNER'S NAME: MOBILIA JOSEPH AND RITA M 356 MATHEW ST DATE ISSUED: 12/17/2015 OWNER'S PHONE: 4084463688 SANTA CLARA, CA 95050 PHONE NO: (408) 727-9850 LICENSED CONTRACTOR'S DECLARATION 9 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL y INSTALL (N) PROPERTY LINE CLEANOUT (SUNNYVALE License Cl Lic.I# SANITARY). Contracto>?CyZe,J"/ f d� .0 ( Date'` r 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: $4400 pg�formance of the work for which this permit is issued. d1laave and will maintain Worker's Compensation Insurance, as provided for by APN Number: 36922033.00 Occupancy Type: 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 PERMIT EXPIRES + IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WIT AYS OF IT 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 fFD� PECTION. indemnify and keep harmless the City of Cupertino against liabilities, judg costs, and expenses which may accrue against said City in consequence of the Issued Date: Z granting permit. Additionally, th applicant understands and will comply �hll no oint source regulatio per he Cupertino Municipal Code, Section wit . 8. ig atuce� Dae /�I/ 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 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 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(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 Mu ' 'pal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, S timff25505, 55 3 nd 25534. Section 3700 of the Labor Code, for the performance of the work for which this ------ ��( Owner or authorize agent: x Date; J 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 .h: _ GENERAL PERMITAPPLICATION ,� `� M E P C0MMUNITY DEVELOPMENT DEPARTNiEN T • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (=;08) 777-3333 • buildin0(a CUDeriino.orq CUPERT[%�0. � 5,�� . Y/11PLUhTBITG ❑ MCN_ANICAL I—IELEC=CA.L nhriI�CELL4� C�T;c PROIrCT ADDPaSS 1 .5P?� - / � 33 L4r 5 DR OVvTrRl�A1JTE / "-�OI�,) e- . I E•I✓i=.�Z A / y S T REFI ADDRESS _ CITY, STATE. ZiprX L FAX 2 01 COINTACT I\AI✓tE _ G�c STREET A-DDRESS CITY, STATE,ZIP I FAX ❑ ovm=, ❑OR2 `?-3U Ti�� ❑ OF t AG�T ❑ com? 4 CTOR ❑ CONFIRACTOR AGTT ❑ .tRCF=—CT ❑ EvGL R ❑ DB�CLOP=R ❑ 7EKIL Kr COIF TRkCTOR NAJiart ' / ` / / LICENSE I�ZTh LICENSE I Y'PE� BUS. LTC' COIdP.fiIY1;Al� E•N.AIL FAX rq_ STREET ADDRESS'/7 I ^ TY, S -ATE, ZiPp �E 85'C� ARCAITECTENGINFER NAME LICi1TSE?\UA SER BUS. LIC C0Id3ANY' AI E E-WUL I FAY STREET ADDRESS CITY, STATE, ZIP I PHONE USE OF ❑ Sr -D, or DUPLEX ❑ MULTI -F Ab,ZLY PROJECT IN' V'II.DLF �'D ❑ YES I PROicCT IN ❑ YEs IS TI -M BLDG AN ❑ Y: -:s BUMDENIG: ❑ CO2'n,,CLQ URB N D=FACF- AREA. ❑ 1.'o FLOOD ZONB ❑ NO EICF? ER HOW.=? ❑ NO DESCRIPTION' OF 7VORK / l .. TOTAL VALUATION: By my signature below,"i certify to each of the follow' g: I - the property owner or autho ' nt to act on the prope. ty owner's behalf. I have read this applicztion and the information I haysprovided is coir- - the.,Description,of l� ak and verify itis accurate. I agree to comply with all applicable local ordinances and state Iaws relat: building con -.. ca I authorize representatives of Cupertino to enter the zbove id -ratified property for inspection purposes. Sig aat:re ofA.pplica ` _ _ Date: G P LEMrENTAL LNFOR-MATION REQUIRED s z Map; SEO�Ll TSCr LNIR h 7 OI£R:TiiECOtIER,:, l�,Tl tin •:� S �.ST�'�'D �Dr Y'' L a . z ❑'e?"4b70R 4 r x A,'EP1i1i7sc,4pp_2011.doc remised 06/21/11 .0t CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10776 w estates dr DATE: 12/1712015 REVIEWED BY: MELISSA APN: 369 22 033 BP#: *VALUATION: 1$4,400 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex USE: -T 2U, "JI, 1rrs.,.,. 1 PENTAMATION 1 RPSS 1PERMIT TYPE: WORK INSTALL (N) PROPERTY LINE CLEANOUT (SUNNYVALE SANITARY) SCOPE APPLIANCE / EQUIP TYPE FEE ID `.'xc, Plop Chez,,,A J.I I QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 2U, "JI, 1rrs.,.,. 1 1 # $25 eel". Plnn ( I I Plumb. Plan Check 0.0 1 hrs $0.00 `.'xc, Plop Chez,,,A J.I I P.oraii"f" CC: Plumb. Permit Fee: IPPERMiT Pem;if Insp. 0 Other Plumb 0. 0 1 hrs 0"her 1"A". 2U, "JI, 1rrs.,.,. 1 P' HMb, bltjIp, 1",,e: PME Plan Check: 10TE: 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 preliminary information available and are only an estimate. Contact the Dept.for addn'l info. FEE ITEMS (Fee Resolution 11-053 Aff.* 7111132 FEE QTY/FEE MISC ITEMS Phin S'14/ 1. Kyfi`ee PME Plan Check: $0.00 Supj-d, jql.�J.3]-`£%-'11 Lj PME Unit Fee: $25.00 PNM Permit Fee: $48.00 ('.,'on, it'I'lClioll Tax: Administrative Fee: IADMIAr $45.00 Work Without Permit? 0 Yes (D No $0.00 Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $0.57 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $167.57 $0.+ TOTAL FEE':: 00 $167.57 Revised: 10/01/2015