12100116 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS 22086 1101 IBSTEAD RD COMT2ACI'OR:" PFRI\IIT NO: 12100116
OWNER'S NAME: MOONEY DIANE N I /.( DATE ISSUED: 10/152012
OWNER'S PlIONE: 6509628492 PHONE NO:
❑ LICENSED CON'rRACI4 — c- -sr,
^'OR'S DECLARATION JOR DESCRIPTION: RES1DIiNTIAI, COMMERCIAL
License Class�1 / 4
7�`,Lic.N — c- -3G INSTALL NEW SEWER LINE AND PROPERTY LINE
CLEANOUT
ContractorT11 19A�,4 (o.tut Dme 10—IS-12-
1
0—IS—/Z1 hereby affirm 15hat I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Ilivision 3 of the Business&Professions
Code and that my license is in full force and effect.
hereby affirm under 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 Labor Code,for the �r h 1
A3"
performance of the work for%%hich Otis permit is issued. Sq.Ft Floor Area: t\_alualm a 5vb
I have and will maintain Worker's Compensation Insurance,as provided for by �`1\
Section 3700 of the Labor Code,for the performance of the work for which this \I'N Number:32602007.00 r y calpaW y"Type:
permit isissued. � `�
AI'PI,IC,\N'I'CFRq'I FIC.CI'10N �
1 cenify that I have read this application and state that the above information is PERMIT EXR111 �. •ORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN I80?iP 'S OF PERMIT ISSUANCE OR
to building construction,told hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FI&TAST CALLED INSPECTION.
indemnify and keep harmless the Cit•of Cupertino against liabilities.judgments,
grans,and expenses which may accrue against said City rconsequence of to /y//L -/r�
granting of this permit, Additionally,the applicant underslanJs:uhd will comply Issued by: �V Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18..
/ RF:ROOFS:
Signature Date / Z All roofs shall be inspected prior to any rorfmg material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ OWNER-BUILDFR DECLARATION
Signature of Applicant: Date:
I hereby affirm that I ora exempt from the Contractor's License hw afor one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BEI-1'ER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IIA"LARDOIIS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safety Code.Sections 25505.25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino dlunicipal Code,Chapter 9.12 and the
declarations: Health&Safely Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined be the Ray Area Air Quality Management District
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Alunicipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilcalth&Safety Code,Se s 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
pOwner or authorized
permit is issued. agent: Uate
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation Imvs of California. If,tiller making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
\I'1'hIG\N'1'CI?RTIFIC,\'PION Lender's Address
I certify that I have read this application mid state that the above information is
correct. I 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
upon the above mentioned properly for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCIIITECI"S DECLARA'T'ION
costs,and expenses which may accrue against said City in consequence of die I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 22086 Homestead DATE: 10/15/2012 REVIEWED BY: jsg
\PN: BP#: 'VALUATION: $4,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTA,MATION' 1RPSS
USE: PERMIT TYPE:
\YORK Instal new sewer line and property line cleanout
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTl' UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
TOTALS: $23.00
,Meeh. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elee.Plan Check
Meeh. Perth Fee; Plumb. Peril Fee: IPPERMIT rice. Permit Fee:
Other,Mech. Insp. Other Plumb Insp. 0.0 hrs L$45.00 Other F-lcr.hisp.
,Meeh.Imp. Fee: Plumb. hesp. Fee: Flee.Insp. Fee:
NOTE: This evintnte does not include jeer due to other Departments(i.e. Planning, Public If'orks, Fire,Suntory Sewer District,School
District, etc.). These feav are based on the prelindnan information available and are onll'an estinuue. Contact the De t or adda'I info.
FEE ITEMS (Fee Resolution 11-053 E/r 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Srtppl. PC Fee
PME Plan Check: $0.00
Per,nir Fee:
Sup/)/. Insp Fee
PML' Unit Fee: $23.00
PME Permit Fee: $45.00
Ctnsnnrction Tax:
Administrative Fee: IADMIN $42.00
Work Without Permit? O Yes (F) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA PDOC $45.00
Strone Motion Fee: IBSFISMICR $0.50 Select an Administrative Item
Bide Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $156.50 $0.001 TOTAL FEE: $156.50
Revised: 10101/2012
GENERAL PERMIT APPLICATIONME
COMMUNITY DEVELOPMENT DEPARTMENT t BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 w I
CUPERTINO (408)777-3220 t FAX(408)777-3333• bulldlnO(70 CUDerilno.OrO '\v/' v\
°LUMBING ❑MECHAMCAL ❑ELECTRICAL ❑MISCELLANEOUS /�/001/�
PRO=ADDRESS • ?08� // _
ON•n & J- I AFN9 3,2& -OP-00-7
OWNER NAME I D (� O I "U" PHO S l Z E-MAIL
STREETADDRESS I CITY. STATE.ZLP I FAX
CONTACT NAME PHONE z.psAlL
A0�1 - 93U h !L/ss.Corn
STF=ADDRESS U I CTTY,STATE ZIP FAX
❑ OWNM- ❑ OWNER-BUILDER ❑ Ou'NR ACONTRACTOR ❑CONTRACTOR AGcT ❑ ARCF;'TECT ❑ENGA'EDt ❑ DEVELOP,-'-ti ❑ IANT
CONTRACTOR NAME llCENS�Nl;NS9ER ENSE E� I BUS.LICA
,'1
COMPy
M'Y NAME k-CSI MAIL /' A aIP S.CCu++ O - -�Cl$1-
111)1%6S
ARQiTTECTIENGINE'r.R NAME LICENSE NUMBER, BUS.LIC p
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE -
USE,OF ElMI.LE
SMv DUPLEX ❑ MU FAMILY PROTECT IN WB.DIUND 0 YES PROJECT IN ❑ YES I IS THE BLDG AN El YES
UB
BNG: CORCLU. URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME'I ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: �G�, I RECEIVED BY:
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. 1 have read this
application and the information I have provided is corr_cL I have read dte Description of Work and verify it is accurate. I agm-to comply with all applicable local
ordinances and sats laws relating to building ewnsruction. i authorim mpreseaatives o.`Cupenino to enter the above-idend5edprope ry for inspection puf�)oses.
Signature of Applicant/Agent: n Date:
SUPPLEMENT OR.NLATION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
❑ EXPRESS
U
❑ STANDARD
U
❑ LARGE
❑ MAJOR
MEPMuc:App2011.doc revised 06/21/11