B-2016-1288 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1288
21331 COLUMBUS AVE CUPERTINO,CA 95014-4921(362 04 002) (A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC)
MEMPHIS,TN 38120
OWNER'S NAME: MA PETER N AND CINDI Y TRUSTEE DATE ISSUED:02/01/2016
OWNER'S PHONE:408-510-9382 PHONE NO:408-982-0405
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class c36 Lic.#Z65155
Contractor(A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA X BLDG —ELECT X PLUMB
INC Date 2/1/2016 _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 JOB DESCRIPTION:
license is in full force and effect. Install(I)property line cleanout"Cupertino Sanitary"
I hereby affirm under penalty of perjury one of the following two declarations: ,
1. 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. t ? r
2. 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:$555.00
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 362 04 002
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 PERMIT EXPIRES IF WORK IS NOT STARTED
harmless the City of Cupertino against liabilities,judgments,costs,and WITHIN 180 DAYS OF PERMIT ISSUANCE OR
expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will 180 DAYS FROM LAST CALLED INSPECTION.
comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. f
Issued by: 1981 � A
'' •
Date:2/1/2016 �lJ
Signature Date 2/11/2016
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of the installed without first obtaining an inspection,I agree to remove all new materials for
following two reasons: inspection.
1. 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 Signature of Applicant:
for sale(Sec.7044,Business&Professions Code) Date:2/1/2016
2. 1,as owner of the property,am exclusively contracting with licensed
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. I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will
2. I have and will maintain Worker's Compensation Insurance,as provided for maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
by Section 3700 of the Labor Code,for the performance of the work for which Health&Safety Code,Section 25532(a)should I store or handle hazardous
this permit is issued. material. Additionally,should I use equipment or devices which emit hazardous
s. I certify that in the performance of the work for which this permit is issued,I 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
compliance with the Cupertino Municipal Code,Chapter 9.12 and
theHealt &Safety Code,Sections 25505,25533,and 25534.
Worker's Compensation laws of California. If,after making this certificate of
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:2/1/2016
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance
I certify that I have read this application and state that the above information is of work's for which this permit is issued (Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws Lender's Name
relating to building construction,and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Address
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally,the applicant I understand my plans shall be used as public records.
understands and will comply with all non-point source regulations per the
Cupertino Municipal Code,Section 9.18. Licensed
GENERAL PERMIT APPLICATI®N BX16103 MEP
Ilia COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE o CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•building(Dcupertino.org misc
E&LUMBING ❑MECHANICAL ❑ELECTRICAL ^ [:]MISCELLANEOUS
PROJECT ADDRESS �� � ` S �� APN#
OWNER NAME,,1 n � c� PH(�C O o �l�,-•��j O� EMAIL
STREET ADDRESS�Y J CITY, STATE,ZIP FAX
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CONTACT NAME PH E-MAIL
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STREET ADDRESS CITY, v A / FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAM LICENSE NUMBERL ENSE TYPE BUS.LIC#
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COMPANY NAME E-MAIL '� FAX
STREET ADDRESS CITY,STATE ZIP TONE
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ARCHITECT/ENGINEER NAME U LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WH,DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
J
TOTAL VALUATIO RECEIVED BY.
By my signature be w,I certify to each of the following: I am the property owner or authorized agent to act on the pr perty owner's behalf. I have read this
application and the infonnation 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.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE usE oivLi
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO p21�?I
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21331 Columbus Ave DATE: 02/01/2016 REVIEWED BY: PAUL
APN: 362 04 002 BP#: *VALUATION: $555
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPS
USE: PERMIT TYPE: A
WORK Install N property line cleanout"Cupertino Sanitary**
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $25
TOTALS: $25.00
=I'ech Ak'n C'>..<': Plumb.Plan Check 0.0 hrs $0.00
tet;Yd. /'ee: Plumb.Permit Fee: 1PPERMIT ;�:£>£;•.t'£ennit I�F:E;::
t,:; F. Other Plumb Insp. 0.0 hrs $48.00 t?ti?e /:i c.?rsz;.
.-Ve""hZ jnsv"1'r'e': 1'dd nb.1?ZS•}J.z`y"c': - ,.`:f£.'£:..r77Sj.%..r"£'£'.:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are onl an estimate. Contact the De t or addn'l info.
"FEET I7TEpMS (Fee.Resolution.1.1-053. ff 7,1/.13) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
P.ermir Pees:
PME Unit Fee: $25.00
PME Permit Fee: $48.00
sl;'t+et1,0— l'tz:,
Administrative Fee: , IADMIN $45.00
Work Without Permit? C) Yes 0 No $0.00
Travel Documentation Fee: ITRA VDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blda Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $167.50 $0.00 TOTAL FEE: $167.50
Revised: 01/01