B-2016-1221CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1221
21912 LINDY LN CUPERTINO, CA 95014-4832 (356 24 015)
(ALLSTAR PLUMBING
CORPORATION)
SAN JOSE, CA 95112
OWNER'S NAME: RODERT ROBERT C TRUSTEE & ET AL
DATE ISSUED: 01/20/2016
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. 467 6%_7G
Contractor (ALLSTAR PLUMBING CORPORATION ) Date//—? C)
X BLDG _ELECT X PLUMB
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
REPLACE BUILDING DRAIN/SEWER LINE UNDER SFD ONLY (NO
I hereby affirm under penalty of perjury one of the following two declarations:
EXTERIOR WORK)
r. 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
performance of the work for which this permit is issued.
OP 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
Sq. Ft Floor Area:
Valuation: $4000.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county
356 24 015
356
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, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAY DD INSRECTION.
Code, Section 9.18.
,
Signature Date.// Z � �
Issue
Date:d by: 1 � Z Q
OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three declarations:
1. 1 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner or authorized agent:
be deemed revoked.
Date
'air 12d
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
Professional
Signature Date
GENERAL PERMIT APPLICATION MEP
4 COMA/iUNITY DEVELOPIdiENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPER71 NO, CA 9501'-3255
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By my signatze below, I certify to each of the =ollowivQ:
I z -nn the prope_-ty owner Or au`horiz 2Qent to act on the prepe. ehz>i. I hzve rend this
apphut;ou and he L--1fo_nmaxion I have provided is correct.
I have- read the Description of 'Work -Ld ven'fj it is zccu ate. I _: ee to comply;; ith z11 eaaliczble local
ord-a_ces and state laws relatun.0 to buiidii, cons1uction.
I au 1, _e representatives of Cume no to enter ue z� e-irieati�ea pro erty for i*i pection pu poses.
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1 rEP_7lisc.4vp_?OI L doc revised 06121/11
CITY OF CUPERTINO
W�907 FEE ESTIMATOR - BUILDING DIVISION
imlADDRESS: 21912 LINDY LN
Plumb. Plan Check 1 0.0 1 hrs $0.00
DATE: 01/20/2016
REVIEWED BY: MELISSA
APN: 356 24 015
1 BPN: B-2016-1221
*VALUATION: 1$4,000
*PERMIT TYPE: Plumbing Permit
Other Plumb Insp. 0.0 hrs $48-00
PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex
USE:
1 h'z
$0.00
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
REPLACE BUILDING DRAIN/SEWER LINE UNDER SFD ONLY NO EXTERIOR WORK)
SCOPE
VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer Mstrict, School
District, etc.). Thesefees are based on the preliminary information available and are only an estimate. Contact tneueptjor aaan'i info.
FEE ITEMS (Fee Resolution 11-053 Eff.' �711113
Plumb. Plan Check 1 0.0 1 hrs $0.00
!.",7'ec' Plo;'?
MISC ITEMS
Plumb. Permit Fee: IPPERMIT
C' perli"f,
S-ITJ.IL PCT ee,
Other Plumb Insp. 0.0 hrs $48-00
1 h'z
VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer Mstrict, School
District, etc.). Thesefees are based on the preliminary information available and are only an estimate. Contact tneueptjor aaan'i info.
FEE ITEMS (Fee Resolution 11-053 Eff.' �711113
FEE
QTY/FEE
MISC ITEMS
S-ITJ.IL PCT ee,
PME Plan Check:
$0.00
Permit 17ee"
Sul.y.V, k1sp.F(-!C
PMEE Unit Fee:
$25.00
PNM Permit Fee:
$48.00
(I" I onstruction 7ilx:
I
Administrative Fee: 1,4DMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.52
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS " ;TOTAL
$167.521
$0.00 Et,
Revised: 01/01/2016