B-2017-1939 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1939
1092 DERBYSHIRE DR CUPERTINO,CA 95014-5003(362 21 041) CLEAR DRAIN
CORPORATION
LOS GATOS,CA 95031
OWNER'S NAME: YOUNG ALAN ET AL DATE ISSUED: 11/13/2017
OWNER'S PHONE:408-598-1507 PHONE NO:(408)358-3242
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36:C-57 Lic.#833802
Contractor.CLEAR DRAIN CORPORATION Date 12/31/2018 X BLDG _ELECT X PLUMB
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
license is in full force and effect. JOB DESCRIPTION:
INSTALL PROPERTY LINE CLEANOUT
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
.er 'rmance of the work for which this permit is issued.
.ave 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:$1500.00
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 362 21 041
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.
000,
gnature Date 11/13/2017 Issued by:AbbyAyende
Date: 11/13/2017
OWNER-BIM LR 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 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:11/13/2017
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
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
sfiallnot 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,Sect'.ns 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall ,,�
be deemed revoked. diner or authorized agent:
APPLICANT CERTIFICATION Date:11/13/2017
I certify that I have read this application and state that the above information is CO STRU O.LEND I G 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. I understand my plans shall be used as public records.
Licensed
Signature Date 11/13/2017
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
r g
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
; rnsr«° (408) 777-3228 • building@cupertino.org PEMIT#B- i •C)n 1
CUPERTINO REVC DEFE
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.1. ❑MEP/�❑RE-ROOF ❑SWIMMING POOL/SPA
PROJEQ' 9 I APN; l.Y, 1`` 0,4 I
P 15)1si-tire- Dr,
11
OWNER NAMEP NE
1q few yo 0,?- ) � � /� IE-MAIL
STREET ADDRESS 6 CITY, STATE,ZIP
1 og)._—De-0 yst re _.1✓la` — —
,,0'CONTRACTOR NAME 0 OWNER-BUILDER COMPANY NAME . LICENSE NUMBER LICENSE TYPE
-k-A2,o !ter' pr y f1 83 36 -S^7
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•
64-
STREET�ADDRESS� �/ CrIY,SPATE, ZIPS I
E-MAILVV ��J?J? b PHON L BUS.LIC F
0 ARCHITECT ❑OWNER.❑OWNER AGENT 0 CONTRACTOR AGENT❑ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON 777 A_
•
❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL ❑COMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF I PORCH SF DECK SF DEMO SF STORIES 9 TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
•
REMODEL REMODEL KITCHEN REMODELOTHR GARAGE 0 ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING
S SPRINKLERS 0 ES EICHLER 0❑ YES SECOND STORY ADDITION DYES
FIRE
0 NO
DWELLING SECOND DWELLING ❑yES 0 ATTACHED DETACHED OTHER
UNITS.# UNITADDITON: 0 N SF
POOLS ❑FIBERGLASS ❑VINYL-LINED 0 GUNITE ❑PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO I TOTAL-SF
RE IVSD BY: 0 I[a t L ALUATION:
Commercial or Mulli•Fmni6t Buildings with Public.Sminunine Pools renulees Department of Environmental Heath approval lN1
RE-ROOF EXISTING ROOF TYPE: 0 BUILT-UP ROOF ID ASPHALT SHINGLES WOOD SHAKES❑WOOD SHIN LES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE I]NO IF NO PLYWOOD El'A"
❑3/8" . PLYWOOD TYPE: PITCH: ROOF CLASS
❑YES I OF LAYERS THICKNESS 0 5!8" OTHER ❑Oss ❑CDX OTHER :12 A A.
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES ❑OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF ;of SQUARES
By my signature below I certify 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 building construction: I authorize representatives of Cupertino to
enter the above-identified property for ins;-ction purpose . I acknowledge and authorize all information cont fined on this application form
to be made available for public record. �����17
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION R.1UIR •
"New SFD/Second Dwelling Units/M 'tifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
"Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
"Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17
stag 1'0
CUPERTINO SANITARY DISTRICTi S S _
20863 Stevens Creek Blvd#100, Cupertino, CA 95014 f `�
Tel(408)253-7071 • Fax(408)253-5173 ,,,,. ,,Eb CUPERTINO
•
SANITARY DISTRICT PERMIT T,E,TrER
Cupertino Sanitary District has adopted Resolution No. 1263.
Building Permit Request
(Over-the-Counter)
jSingle Family Project D Multi-Family Project n Commercial Project
Project Address: /01 4 De f f5y51••4-ve_. 6urrey-77-,c (f . . of
Permit Number: 1-6'.7,00---.0 Vi
Scope of Work: ,p«$elkT j,t , c t 0-r
Owner/Applicant Name: 41i ois I Phone: q0p ,51ls--o
Address: C(257 Per 6
yew, e
Date: \ 1 Ib 1 I Prepared By: ( A1 t
Cty Authorized Representative
I, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements
will be met nd all required fees will be paid prior t" e approval of final inspection for proposed project.
Date: 7 1;S/7 _ Signature:
awner/Authorized Agent
CUPERTINO SANITAr DISTRICT OFFICE USE ONLY
E Pre-inspection Required . X Final Inspection Required
Date Scheduled:
Date: Conditional Approval By:
• Authorized Representative
Cupertino Sanitary District
District will notify•owner of the required fee within 5 days after Pre-lnspection has been completed and cc
City of Cupe 'no. •
Inspection Fee Paid Date Paid: I I— 13 - 17
Inspe io Fees:
$250/unit- Single Family Residential already connected, but new cleanout is required
MI $150/unit- Single Family Residential already connected with existing cleanout in working order
0 $350 Minimum—Commercial and.Retail Actual Amount:
O $200/each —Disconnect and/or abandon lateral service
Connection Permit Fees: ,
0 $350/unit- Single Family Residential connecting to existing lateral
0 $650/unit—Single Family Residential connecting with new lateral
0 $100/unit—Multi, Hotel, Living Units, etc. Actual Amount:
0 $500/connection - Commercial and Retail Actual Amount:
Connection Use Fees(See Attached Calculation Sheet):
0 Area and Frontage Fees Amount:
Residential Excess Fees over 3.5 unit/acre Amount:
0 Commercial and Retail Connection Fees Amount:
0 Commercial and Retail Change in Use Fees Amount:
Date: /1 / 3 - / 1 Final Approval By: 9-
_di&
Auth•` ized Representative
Cupe . --nitary District