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B-2017-0173 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2017-0173 10186 CAMINO VISTA DR CUPERTINO,CA 95014-2608(342 14 056) CUPERTINO PLUMBING INC SAN JOSE,CA 95124 OWNER'S NAME: HAYNES GLORIA MARIE TRUSTEE&ET AL DATE ISSUED:01/27/2017 OWNER'S PHONE:650-340-8764 PHONE NO:(408)253-0618 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C--3_Q Lic.#624905 Contractor CUPERTINO PLUMBING INCDate 04/30/2018 X612 BLDG_ELECT X PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL— COMMERCIAL with Section 70.00)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: CLEAN-OUT-PROPERTY LINE t. 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. 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 permit is issued. Sq.Ft Floor Area: Valuation:$2000.00 APPLICANT CERTIFICATION 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 342 14 056 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 expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 01/27/2017 Issued by:Kim Dunbar �_ Date:01/27/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS. following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages as their sole metalled without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Scc.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:01/27/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I. 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. HAZARDOUS MATERIALS DISCLOSURE z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: 1�_�'< -� APPLICANT CERTIFICATION Date:01/27/2017 I certify that I have read this applicationand state that the above information is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 91/27/2017 Professional GENERAL PERMIT APPLICATIONKEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE�CUPERTINO,CA 95014-3255-' Ct PERTItiIC (408)777-3228• FAX(408)777-3333•buildinaRcupertino.org 6 w( 1-0 r-P-> mist; PLUMBING []MECHANICAL ❑ELECTRICAL QMISCELLANEOUS PROJECT ADDRESSff r i2 (� V� } J_ API. �1J ��/ D�-/�, OWWNERNAME PHO J`' -7 () U ? E-MAIL C� ' SF' STREET ADDRESS f /' /� CITY,STATE,ZIP FAX, e,rbp-70 CONTACT NAME u I--,— .V9 -- � r-M 0 r �Q✓` ✓ / AJL STREET ADDRESS te"3 CITY,STATE,ZIP I -- FF ❑ OWNER ❑ OWNER-BULDER ❑ ORWTERAGE!�*T dJ CONTRACTOR ❑0 CONTRACTORAGEIQT ❑ ARCHITECT ❑ENGNIEER ❑ DEVELOPER ❑ TENTANT CONTRACTOR NAMEj^ j � ��� LICE' F,�viB�Flj�®� LI ISE TYPEEE � ! BUS.LIC n COMPANY NAME C j V`� E-17AR FAX S CITY,STATF�„ZIP d--4 __ J/ PHONE ARCHITECT/ENGTNEER NAME LICENSE NUMBER T BUS.LIC COMPANY NAME E-IVLAIi FAX — — STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-F_A DLY PROSECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BL=L\TG: ❑COTRMERCLAJ. i URBAN II.TERFACE AREA ❑ NO FLOOD ZONTF ❑L.'O EICHLER HOME? ❑ Id0 DESCRIPTION OF WORK o -f- f TOTAL VALUATION: By my signature below,I cer6fy to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and.the information I have provided is correct. I have read the Description of fork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I&Uthorize representatives of Cupertino to enter the above-identified property for inspection.purposes. Signature of Applicant/Agent: Date: l72� SUPPL 4ENTAI INFORMATION REQUIRED oFi ICE USE o I Y © Ol EM"THE COi7IYTER { © E7 PRESS Y- J L - © STANDARD "- © LARGE ,s --TTAJOR -- A1EPMiscApp_2011.doc revised 06121111 40 CUPERTINO SANITARY DISTRICT -s' & 20863 Stevens Creek Blvd#100,Cupertino,CA 95014 Tel(408)253-7071 - Fax(408)253-5173 CUPERTINO SANITARY DISTRICT PERMIT I E1'TER Cupertino Sanitary District has adopted Resolution No. 1263. Building Permit Request (Over-the-Counter) 0 Single Family Project F-1 Multi-Family Project ❑Commercial Project Project Address: 10186 Camino Vista Dr, Cupertino, CA 95014 - Permit Number: E 20 ["r"+- 0 L-13 Scope of Work: Install a new property line cleanout Owner/Applicant Name: Flora Wheldon Phone: 408-340-8764 Address: -4 + Ca_,4117(40 LhS -/ DAL. Date: - 1/27/17 Prepared By: City Authorized Representative 1, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements will be met and all required fees will be paid prior to the approval of final inspection for proposed project. Date: 1/2-7AI - Signature: 'Owner/Authorized Agent CUPERTINO SANITARY DISTRICT OFFICE USE ONLY F-1 Pre-inspection Required px� Final Inspection Required Date Scheduled: A�r Date: 1/27/2017 — Conditional Approval By: Authorized presentative Cupertino Cupertino Sb itary District District will notify owner of the required fee within 5 days after Pre-inspection has been completed and cc City of Cupertino. 0 inspection Fee Paid Date Paid: 1/27/17 Inspection Fees: 1571 $250/unit-Single Family Residential already connected,but new cleanout is required = $150/unit-Single Family Residential already connected with existing cleanout in working order F__1 $350 Minimum—Commercial and Retail Actual Amount: = $200/each—Disconnect and/or abandon lateral service Connection Permit Fees: CI $350/unit-Single Family Residential connecting to existing lateral $650/unit—Single Family Residential connecting With new lateral $100/unit—Multi,Hotel, Living Units, etc. Actual Amount: $500/connection-Commercial and Retail Actual Amount: Connection Use Fees(See Attached Calculation Sheet): Area and Frontage Fees Amount: Residential Excess Fees over 3.5 unittacre Amount: Commercial and Retail Connection Fees Amount: Commercial and Retail Change in Use Fees Amount: Date: L)::, I I Final Approval By: Authorized Repentafive Cupertino Sanitt District