B-2017-0648i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0648
10308 ALPINE DR APT A CUPERTINO, CA 95014-0912 (326 15 071)
ROOTER HERO
PLUMBING INC
MISSION HILLS, CA
91346
OWNER'S NAME: ZUBRYCKY ZENON AND VERA TRUSTEE
DATE ISSUED: 04/25/2017
OWNER'S PHONE: 408-685-2170
PHONE NO: (888) 929-4376
i
LICENSED ONTRA TOR' DECLARATION
BUILDING PERMIT INFO:
License Class C-36 Lie. #973014
Contractor ROOTER HERO PLUMBING INC Date 05/31/2018
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:
SEWER LATERAL REPLACEMENT WITH PROPERTY LINE CLEAN .f
I hereby affirm under penalty of perjury one of the following two declarations:
OUT
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
permit is issued.
5q. Ft Floor Area:
Valuation: $8085.00 i
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
326 15 071
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 regulatio p r the Cup rtino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature 4Date 4/25/2017
Issued by: AbbyAyende
Date: 04/25/2017
OWNER -BUILDER DECLARATION
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 ford
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: 4/25/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "AllOR 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. 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 Cope r ' o Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health &Safety Code, Sec ' ns 25505, 2 33, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
_
be deemed revoked.
Owner or authorized agent: p�
APPLICANT CERTIFICATION '-bate:
4/25/2017
I certify that I have read this application and 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
Si
Signature Date 4/25/2017
g
Professional
GENERAL PERMIT APPLICATION M E mpmmh'
COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION
10300 TORRE.AVENUE • CUPERTINO, CA 95014-3255 nil ffCUPERTINO
)1:41TaA-PTNT(, i IT/fL'/ AT"T AT r7-. r-,. .� ,
(408) 777-3228 •FAX (408) 777-3333 • building a(�cupertino.ar
PROTECT ADDRESS
)
APN # f �� fl �
OWNER NAME � � � r
Ui
f PHO_0 �%O - � � � �` E-NLAIL
1 �9
STREET ADDRESS
CITY, STATE, ZIP FAX
CO *TACT NAME all �ltM
PH x� y P_� J E P
U �j ��t0, CLtAa S JA N, C1� +tj.
STREET ADDRESS
f e(l� l��
CI , STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWIQERAGENT
CONTRACTOR ❑ CONZTRACTOR AGENT ❑, ARCHITECT ❑ ENGLNTEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NA �-� ��
\
LICEN .IBR
LICENSE TI p,E�
BUS. LIC
`g1
COMPAI Y NAME �^�//
Ji j
E:&U
FAX
°Cw�+
STREET ADDRESS-7CITY,
Z l� �e
STATE, ZIP
%vl 5711
ARC!-ETECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC f
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
I CITY, STATE, LIP
PHONE
USE OF .I� SFD or DUPLEX ❑ MULTI-FAMII,Y
BUTLDLNG: ❑COMMERCIAL
PROJECT IN WIIALAND ❑ -YES PROJECT IN ❑ YES
URB AN INTERFACE AREA E] NO FLOOD ZONE E3 No
IS THE BLDG AN ❑ YES
EICHLERHOME? ❑NO
DESCRIPTION OF WORK
TOT.4LVALUATION: i
✓
RECEIVED
i
By my signature below, I c -tify to each of the following: I am the property owner or authorized agent to act on the property owAer's behlalf. I have read this
application and the information I have pr r disco rrect. 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 rld- g construction i authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USEaI.I 1
y _
❑ 01 ER THE COI1tTER
L'
'❑ E�PRBSS
-STAN A
� -
:'❑ L4RGE
A,fEPMiscApp_2011.doc revised 06/21/11
dc�
CUPERTINO SANITARY DISTRICT
20863 Stevens Creek Blvd #100, Cupertino, CA 95014
Tel (408) 253-7071 • Fax (408) 253-5173
Q 9ANtY�Rpo,�sl
CC))
FSpAgttsx�o,g�� CUPERTINO
SANITARY DISTRICT PERMIT LETTER
Cupertino Sanitary District has adopted Resolution No. 1263.
Building Permit Request
(Over -the -Counter)
IN Single Family Project ❑ Multi -Family Project ❑ Commercial Project
Project Address:
Permit Number:
Scope of Work:
Owner/Applicant Name: 4--2 9-o Phone: 46E - Y03 - f7 isclG
Date: L-1'6� n—
V
Prepared By:
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 prio -Vhe approyal of final inspection for proposed project.
Date: _ Z,�~ Signature:
r
er / Authorized Agent
CUPERTINO SANITARY DISTRICT OFFICE USE ONLY
❑ Pre -inspection RequiredFinal Inspection Required
Date Scheduled: jz
Date: Conditional Approval By:
Authorized Representative
Cupertino Sanitary 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: 25 — 1-7
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:
O $200/each — Disconnect and/or abandon lateral service
Connection Permit Fees:
$350/unit - Single Family Residential connecting to existing lateral
$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):
Date: Al- ZS -r -7 Final Approval By:
Authoriz e r entative
Cupertino Sanitary District
Area and Frontage Fees
Amount:
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: Al- ZS -r -7 Final Approval By:
Authoriz e r entative
Cupertino Sanitary District