B-2017-0423CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0423
7443 STANFORD PL CUPERTINO, CA 95014-5814 (359 32 037)
GOLDEN STATE
PLUMBING
SAN JOSE, CA 95112
OWNER'S NAME: LAW PATRICK YAND HO DOREEN
DATE ISSUED: 03/14/2017
OWNER'S PHONE: 408-802-0737
PHONE NO: (408) 849-2329
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-36 Lic. #1005659
Contractor GOLDEN STATE PLUMBING Date 07/31/2017
X BLDG —ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
-- MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
REPLACE SEWER_ LINE AND INSTALL FOUNDATION CLEAN-OUT
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.
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
Sq. Ft Floor Area:
Valuation: $3200.00
permit is issued.
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
359 32 037
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 CupertinoMunicipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature r_� C / –� Date 03-14-2017
Issued by: Kim Dunbar
OWNER-BUILDER DECLARATION
Date: 03/14/2017
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
installed 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 (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 03-14-2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
HAZARDOUS MATERIALS DISCLOSURE
2. 1 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
a. 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
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person any manner so as to become subject to the
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:l ��
APPLICANT CERTIFICATION
Date: 03-14-2017
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
CONSTRUCTION LENDING AGENCY
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,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 03-14-2017
Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPFRTI NL 777-3228 • FAX (408) 777-3333 • building(a�cupertino.org MISC
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USE OF <FSFD or DUPLEX ❑ MULTI -FAMILY
- BUILDING: ® COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
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By my signature below, I ceritIfy 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 Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bu* g construction. I authorize representatives of Cupertino to enter the above -id e fi/f'ieddppx" ert/y for inspection purposes.
Signature of Applicant/Agent: �-- ' Date: _ d / 2'
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SUPPLEMENTAL INFORMATIONREQUIRED
OFFICE♦ USE ONLY
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❑ OVER-THE-COUNTER
❑ EXPRESS.
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1f,PMiscApp_2011.doc revised 06121111
CUPERTINO SANITARY DISTRICT
20863 Stevens Creek Blvd #100, Cupertino, CA 95014
Tel (408) 253-7071 • Fax (408) 253-5173
sNK1114 41
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SANITARY DISTRICT PERMIT I , . ,
Cupertino Sanitary District has adopted Resolution No. 1263.
Building Permit Request
(Over -the -Counter)
Single Family Project ❑ Multi -Family Project ❑ Commercial Project
Project Address: -144:- > S,�-o_" O Z/QA-?N_-t�221SA -7
Permit Number: _ j�j ��
Scope of Work: ��b � i �r c �r a,- ra_Q
Owner/Applicant Name: CL o1,- Phone: 40 ;-7-2 --2c(
�rlrJrccc•
Date:
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:
Signature:
Owner / Authorized Agent
CUPERTINO SANITARY DISTRICT OFFICE USE ONLY
❑ Pre -inspection Required
Date Scheduled:
Date: 3-15- 17 Conditional Approval
Final Inspection Required _�d04T
By.
Authorize c Re',pre entative
Cupertino anit District
District will notify owner of the required fee within 5 days after Pre -Inspection has been completed and cc
City of Cupertino.
❑ Inspection Fee Paid Date Paid:
Inspection Fees:
$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
D $350 Minimum — Commercial and Retail Actual Amount:
D $200/each — Disconnect and/or abandon lateral service
Connection Permit Fees:
D $350/unit - Single Family Residential connecting to existing lateral
D $650/unit — Single Family Residential connecting with new lateral
O $100/unit — Multi, Hotel, Living Units, etc. Actual Amount:
$500/connection - Commercial and Retail Actual Amount:
Connection Use Fees (See Attached Calculation Sheet):
D Area and Frontage Fees Amount:
D Residential Excess Fees over 3.5 unit/acre Amount:
Commercial and Retail Connection Fees Amount:
D Commercial and Retail Change in Use Fees Amount:
Date:
Final Approval By:
Authorized Representative
Cupertino Sanitary District