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12020069
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19520 HOMESTEAD RD CONTRACTOR7�� 7JA ERMIT NO: '2020069 CONSTR INC 0�4'NER'S NAME: SHEARER LOLA F PO BOX 24819 TE ISSUED:02/'5/2012 SAN JOSE,CA HONE NO:(408)377-9990 ONVNER'S PHONE: 4087998776 1:ICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ' ELECT PLUMB License Class Lic.# (n -1 -14 -75 MECH RESIDENTIAL COMMERCIAL Contractor s r Date 0 2 1 Z JOB DESCRIPTION:AL)Q NEW SEWER LINE,ADD NEW PROPERTY LINE I hereby affirm that I am licensed under the provisions of Chapter 9 CLEANOUT (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirtrt tinder 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. Valuation:$5'30 I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31604064.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct t 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save IT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN FROM L OF T CALLED INSPEC` ION. costs,and expenses which may accrue against said City in consequence of the ig� DAA F granting of this permit. Additionally,the applicant understands and will comply 'l with all non-point source regulations per the Cupertino Municipal Code,Section Issued by - �— Date: .CJO Signature ` �.�_ Date O'Z l (Z RE-R ® ()41`NF.,R-BUIL.DER DECLARATION All roots shall be i€tsi)ected prior to any r nat al g msWtY d.If a roof is [atm exempt from the Contractor's License Law for one of installed without first obtaining an ectt I ree rt love all new materials for I hereby affirm that P inspection. the following two reasons: 1,as owner of the property,or illy employees with wages as their sole compensation, Date: will do the work,and the structure is not intended or offered for sate(Sec.7044, Signature of Apph Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL RO@F gO VERINGS TO BE CLASS"a"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 5 of the I have and will maintain a Certificate of Con to self-insure for Worker's Cal forma Health&Safety Code,Sections 25505,25533,under a Chapter 8 d 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 2.5532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which thiscontaminants as defined by tine Bay Area Air Quality Management District I will permit is issued. maintain cornpliance with the Cupertino Municipal Code,Chapter 9.12 and the ance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. I certify that in the perform not employ any person in ay planner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owner or au o1�ednagent: Date: 0 L t ��(f Z must become subject to the Worker's Compensation provisions of the Labor Code,I forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION 1 certify ve information is for which this permit is issued(Sea 3097,Civ C.) that l have read this application and state that the abo correct.I agree to comply with all city and county ordinances and state laws elating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgment.- ARCHITEC;T'S DECLAR4TION costs,and expenses which may accrue against said City in consequence of the orantittg of this permit.Additionally,the applicant understands and will comply tivith all roil-point source regulations per the Cupertino Municipal Code,Section I understand my plaits shall be used as public records. 9.l5. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 19820 homestead rd. DATE: 02/15/2012 TREVIIE7WEDY: bob s.APN: BP#: : $5,130 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition 1 Repair PENTA1ti1ATION 1 RPSS PRIMARY SFD or Duplex PERMIT TYPE: USE: WORK add new sewer line add new property line cleanout. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $22 $22.00 TOTALS: Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Cather Plumb lnsp. 0.0 hrs $44.00 artments(Le.Planning,Public Norks,Fire,Sanitary Sewer District,School NOTE: This estimate does not include fees due to other Dep District,etc.). Theseees are based on the relinsna in ormation available and are onl an estimate. Contact the De i or addn'l info. FEE ITEMS ' ;`0 3; MISC ITEMS FEE QTY/FEE PME Plan Check: $0.00 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? ( Yes Q No $0.00 Travel Documentation Fee: ITRAVDOC $44.00 ; � IBSELSMICR $0.51 Select an Administrative Item } 1 ._ F.e: IBCBSC $1.00 SUBTOTALS: $152.51 $0.001 TOTAL FEE: $152.51 Revised: 1/19/2012 CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg 6 ITEMS OF 6 COPY # Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31604064 .00 DATE ISSUED. . . . . . . : 02/15/2012 RECEIPT #. . . . . . . . . : BSOoOO16021 REFERENCE ID # . . . 12020069 SITE ADDRESS . . . . . 19820 HOMESTEAD RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SHEARER LOLA F ADDRESS . . . . . . . . . . . 19820 HOMESTEAD RD CITY/STATE/ZIP . . . CUPERTINO, CA 95014-0500 RECEIVED FROM . . . . ABLE UNDERGROUND LIC # 29014 CONTRACTOR . . . . . . . MARSHA M. MILLER COMPANY . . . . . . . . . . ABLE UNDERGROUND CONSTR INC ADDRESS . . . . . . . . . . po BOX 24819 CITY/STATE/ZIP . . . SAN JOSE, CA 95154-4819 TELEPHONE (408) 377-9990 . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ---------- ----- ---- --------- ------0___.00 ---------- ------ 1 .00 41 - 00 0 .00 41-00 0 .00 1ADMIN HOURS 1.00 0 .00 1 .00 5, 130 -00 1BCBSC VALUATION 051 0 . 00 0 .51 0 .00 5, 130 .00 . 1BSEISMICR VALUATION 0 . 00 44 .00 0 .00 JPPERMITFE FLAT RATE 1 .00 44 .00 0 .00 22 .00 0 .00 1PRSEWER UNITS 1 .00 22 .00 0 .00 44 .00 0 .00 1TRAVDOC FLAT RATE 1.00 44 . 00 ----- ---------- ---------- ------ --- ----- 152 .Sl 0 .00 152 . 51 0 .00 TOTAL PERMIT : AMOUNT REFERENCE NUMBER METHOD OF PAYMENT ----------- -------- ----------------- CHECK 152 . 51 #18629 TOTAL RECEIPT 152 .51 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 106 SEWER & WATER 400 SEWER/LATERAL 301 ROUGH PLUMBING 507 FINAL PLUMBING GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MISC (408)777-3228• FAX(408)777-3333• buildin cu rtinc.org CUPERTINO ) .11 t� MECHANICAL f ❑-T.F=lCAL ❑MLSCELI-ANEOUS PLUMBING ❑ PROJECT ADDRESS / U �D l� E S 1 c �$ ( r Q `� _ 4-1 PHONE -7 E-MAIL OWNER NAME 1 _ Q �' �,© L T Q 799 l� CITY,STATE,ZIP FAX STREET ADDRESS l S'1 =4 (�Jam–(� N C� �1 PHONE E-MAIL CONTACT NAME n© &� 7-- ��2� TA y D /L CITY,STATE, ZIP FAX STREET ADDRESS � ��l �v,lt E �- C c/ E i . CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT E]ENGINEER ❑ DEVELOPER ❑TENANT 13 OWNER [3 OWNER-13=ER ❑ OWNER AGENT i�� LICENSE 7-7 LICENSE TYPE Bus.LIC# CONTRACTOR NAME4 A AX y _ COMPANY NAME U E-MAIL Z /Oa ,4 11V c G N PHONE CITY,STATE. 7 7 S.�t ` STREET ADDRESS �✓ /O & LICENSE NUMBER Bus.LIC# ,ARCI-IITECT/FNGINEER NAME /–IA— FAX E-MAIL COMPANY NAME' CITY,STATE,ZIP PHONE STREET ADDRESS YES PROJECT IN ❑YES Is THE BLDG AN ❑YES USE OF FD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WILDLAND ❑ O FLOOD ZONE [3 NO EICHLER HOME.) [3 NO BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ DESCRIPTION OF WORK I. i /, RECEIVED BY: [IB3yv TAL VALUATION: V my,siglature 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 bave read this application and the information have provided constructionb I authhave o ze�representati�es of Cupertino t enteron of Work and verify tthe boveis Led nifled prope to yl for�inspection putposes� ordinances and state laws relating g Date: Signature of Applicant `�/ln L�_� SUPPLEMENTAL INFORMA n—N REQUIRED OFFICE USE ONLY m OVER-THE-COUNTER v. ❑ EXPRESS Y U w ❑ STANDARD T U < ❑ LARGE a ❑ MAJOR MSPMisc gpp_2011.doc revised 06/21111