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160100023 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 859 BETTE AVE CONTRACTOR: TRIPLE A PLUMBING PERMIT NO: 16010002 SERVICES OWNER'S NAME: ABHYANKER SONAL PO BOX 5144 DATE ISSUED: 01/04/2016 OWNER'S PHONE: 4083983126 SANTA CLARA, CA 95056 PHONE NO: (408) 245-4940 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL INSTALL (N) PROPERTY LINE CLEANOUT License Class Lic!fic���� Contra �r (�' A— _ Dat MW I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions SANITARY 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: $3800 performance of the work for which this permit is issued. I' a and will maintain Worker's Compensation Insurance, as provided for by ection 3700 of the Labor Code, for the performance of the work for which this APN Number: 36927044.00 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 I D*A 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 18 S FR.OM­ST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence oitition e granting of this permit. Additionally, the applicant understands and will / Issued Date: / b with all non -point source regulations per the Cupertino Municipal Code, RE -ROOFS: 9.18. W6 Signa tul Da,e 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 (See.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 Municipal Code, Chapter 9.12 and 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 the Health & Safety Code, Sections 505, 2 33, and 25534. X Owner or authorized agenfi; �%�0 Date:# permit is issued. I certify that in the performance of the work for which this permit is issued, I shall r 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 t CUP ERT[t-[0 GENERAL PERMi T APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255 (SOS) 777-3228 •FAX (408) 777-3333 • build ina(a)cuoeriino.org � 0 2 — MISU PLU1\4BIlvG ❑i ECHad\ZC.S.L ❑ELECTRIC?L ❑hiqSCELLfiu\�OUS PROT CT kDDPESSZej L � OWNER KAjIM l I PHO17 I c 1✓�-�Z S T REE T ADDP.ESS .q� �i n CITY, STATE, ZIP CONTACT K.4A4Eged Avica(L—P j _� l 5 E 144.7 STREET ADDRESS CITY, STATE, ZIP FAX ❑ uv, � ❑ ❑ Otir tAG T �<COI\TIRhCTOR ❑ CON- ?ACTORAGENT ❑ .kRC?7jECT ❑ NGP.z2 ❑ DB�,tLOPE:t ❑ 1_1ztNj CONTR4CTOR K? -1 r n I LICENSE KUbSER I LICENSE BUS. LIC COMOPAKYN —M jTQ! i�►s i li, f I ✓ E-MAIL STREET ADDRESS CITY, S i AT–, ZIP 14 PH '1� relGUa©y-d ren C )' —PN ARCHITECMEN GLN=R N.sh�B LICENSENUMBER . BUS. LIC' COI✓2, ANY NAI C1 E -W -JI.. STRE?i .4DDR SS CITY, STATE, ZIP I PHONE USE OF D Sr' .. o,:)uPLFx ❑ muLTI-Fium-Y PROJEECT PQ WIIDLF-ND ❑ Y S PROTECT PN ❑ YES IS Tr -P BLDG AN ❑ T"cS BTj=I^G:❑COhG,=, Ci.�—T I L?3RNLN=- FACEA.P.EA ❑ NO FLOOD ZONE ❑ TO EICEII RHOMM7 ❑ T'0 DE.SCRIPTIOK OF)YORK TOTALVALUATION: V0 By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the pro_ ... L owner's behalf. I have read this apphutiou andLb-- information I have provided is co, ect. I have read the Description of'Work and verify it is accurate. I agree to comply with all applicable local ordinances and sate laws relating to bui " g c sectio ' I u boring repres tatives of Cuuertino to enter the above -idea iced property for inspec ion purposes. Si2mature of,' iDlicant/Agent: Date: SUPP_EAiEN1 AL L7\ORvIATI01\T RE LLRED Q ` - = Yxr% 'l OV£1,Ti3F COIi�TER- s, a5. t iARGEl 1 SEP-A/iscnvp_?011.doe revised 06121/11 CITY OF CUPERTINO WRW FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 859 BETTE AVE 'DATE: 01/04/2016 REVIEWED BY: MELISSA MISC ITEMS APN: 359 27 044 1 BP#: . *VALUATION: 1$ 3,800 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: PME Plan Check: $0.00 PENTAMATION I RPSS rPERMIT TYPE: A WORK INSTALL (N) PROPERTY LINE CLEANOUT Suppl–l"'Isp SCOPE L— I 1-,ho7 (7kieck 0.0 1 hrs $0.00 I Plumb. Plan Check Few: Plumb. Permit Fee: 1PPERMT fler"W1 Fe -e.- Other Plumb Insp. 0.0 hrs $48-00 iijSll), I mElee- -11"- "'isp. F�.e bL4°v, Fee: VOTE: Thisestintate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). 11rese.jees are based on tine preliminary inforynatton available ana are onq all estunate. contact tie vept,foraaan-linfo. FEE ITEMS (fee Resolution 11-053 fff. 711113) FEEQTY/FEE MISC ITEMS Pkw Cbeck Fee: F-1 PME Plan Check: $0.00 D " ermit T`ee: Suppl–l"'Isp PME Unit Fee: $25.00 PME Permit Fee: $48.00 Administrative Fee: JADMIV $45.00 Work Without Permit? 0 Yes (F) No $0.00 ,4d'wmce&P1ctnniqg Fe�ay., Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISAECR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $1 67.50 �:�TOTAILEEE:i. $0. $167.50 1 Revised: 10/01/2015