16010037 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10467 N STELLING RD CONTRACTOR:ABLE SEPTIC PERMIT NO;16010037
OWNER'S NAME:. BROWN LESLIE AND AUDREY TRUSTEE 1020 RUFF DR DATE ISSUED:01/06/2016
OWNER'S PHONE: 4088355560 SAN JOSE,CA 95110 PHONE NO:(408)377-9990
JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
LICENSED CONTRACTOR'S DECLARATION ❑ ❑
„- REPLACE 12'+/-OF(E)SEWER LINE&INSTALL(N)
License Class% /_ PROPERTY+- CLEANOUT
Contractor DateA ( JF' � a
a
I hereby affirm that i am Bcensed under the provisions of Chapter 9 � a�1? .� �� '�
(commencing with Section 7000)of Division 3 of the Business&Professions o s ��
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4300
zI 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:32628089.00 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 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 DAYS O D INSPECTIO
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comp ate:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
r / RE-ROOFS:
Signatures Date P( 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
:
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL L 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(a)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,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this r Date:'� —Gil
permit is issued. Owner or authorized agent:z A
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
W. P
GENERAL PERMIT APPLICATION
MEP
w COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
C(1PERTINt3. (408)777-3228 • FAX(4;08)777-3333 • build inofcDcuDerino.org
�6D��v3
❑P G ❑MECHkhIC.A? ❑r L ECTRIC.A ❑]aSCpLLA ouS
FC'MA&E
RO CT ADD ES j f c1V I .S??,_ �`� !d — o "
���� I Pri�. 16
J
S T R ADDR E CITY, STA-,ZIP
CON-m'=T �3 I P IOt� E.Ire
� °'G' C c•e- Ud ( o a�� � � p c°o f
. STREET DP.ESSP/-- ) CITY,STAT=, � E �1 vIf 2 —!®�
❑ OY' ❑ On ?-3'i r0 ❑ OWN-MAG--NT ❑ CONMACTOR ❑CO?,71MRCTORAGMvT ❑ :SRC:17I-CT ❑ ?GT_ER ❑ DEVELOPER ❑ i_KLN"T
COIdTPCTORKAME
COpIJ,FR?.`Y?�,r d P LICB-1WWE
I
�
C E•JZ tetI-e cc,
Ev
STRZTZI
4 ,YTT13g,
'c,TiC
0z jFF
— C?®
Pg l�E
]rofeF7 CA 251/0
«CSTECT�nG =ER1A7SR I LICEITSB-NUh43ZR L
BUS.LIC
E-M-AIL FAX
STREET ADD3'r.SS I CITY,S TATE,ZIP I PFOI1%
USE or- E)SID or DL'?Lr'� ❑ MULTI-FAIOLY I.PROY'CT N a'n DL--\D ❑ = I PROS=CT-N ❑ti zs I IS T BLDG A_N ❑ Y_S
MI
BUMG: COho'=, ,C_A.L L'R3ANLN'I=RiACB POA. El NO FLOOD ZONS ❑ ?''0 MCI=HOME? ❑ mo
DESCP.IFTION OF WORK
TOTAL VALUATION;:
By my signaLu-e below,I c,---6 to each of tb foil owing: I P t]n property 07"ner 0r au!So rzed agent to a ` prepei Ly o
applic ,on and h info tin, I have prop ided is co_.ect. I h2 e read the Desc action of'Wo k and v e, .t is acci_rate ee to
. comply a ith al applicable local
O:d»nC.,S_nd St_ laws relatizng tO/blli1dL_Q CO'1S'SL�i?a�.. I c�1h0IIZe p eSfl:`�ii\SES Of CLU..:��i0 to e0 er tt1.. e-id—tifefd/property Ioi iaiSDectlon purposes.
Sl�_�i.._tLr..of r�?.Ilp�1C"�✓".geLt, [ei\ > Date:
z•
SUPPLEI\Ti—EIiTA?T'I'OR-TATI02\1 REQUL?.P.D
,.
RM _
1�Y A/isc pp_20_11.doc remised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
-T-
ADDRESS: 10467 N STELLING RD DATE: 01/0612016 REVIEWED BY: MELISSA
APN: 326 28 089 BP#: *VALUATION: 1$4,300
'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
SFD or Duplex 1 RPSS
USE: PERMIT TYPE:
WORK INSTALL 12' +/- OF SEWER LINE & INSTALL N PROPERTY LINE CLEANOUT
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1 PRSEWER 1 # $25
TOTALS: , . ...: $25.00
a
M
?,f<h. z';..a(',"heck
k Plumb.Plan Check QO hrs $0.00 l'<,",% 'lea a
Plumb.Permit Fee: IPPERMIT
1 P'< 1.sxPtF3. Other Plumb Insp. 0.0 hrs $48.00
Cc.'• .';slrr'Y'.'.Is'. #I,°.'7,Fee;
NOTE: 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 preliminar information available and are only an estimate. Contact the De t or addn'l in o.
FEEITEMS (Fee Resolution 11-053 Fff' 7/7//:U FEE QTY/FEE MISC ITEMS
Plan C'heek
Su/3pL P(..`. ';c; Ll
PME Plan Check: $0.00
Supl 1. Aisp.17e
PME Unit Fee: $25.00
PME Permit Fee: $48.00
L'onstruclion Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes (j) No $0.00
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $0.56 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
'SUBTOTALS;;.: $167.561 $0.00 TOTAL,FEE; $167.56
Revised: 10/01/2015