13070183 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20387 CLIFDEN WAY CONTRACTOR:MAGIC PLUMBING PERMIT NO:13070183
OWNER'S NAME: JUNG DONALD T AND YOUNG M 658 LAKEWOOD DR DATE ISSUED:07/30/2013
OWNER'S PHONE: 4082571186 SUNNYVALE,CA 94089 PHONE NO:(408)421-2355
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRH'TION: RESIDENTIAL 0 COMMERCIALE]
License Class —� Li,..# n (F2 7'7 2— PROPERTY LINE CLEAN OUT
Contractor G S`L P�s '� Date
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.
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 the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3800
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 APN Number:36937013.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA F M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the e
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-poi source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature 2-- Dater 3 - 1,3 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)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 by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the upertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti25505,25533,and 25534.
Section 370.0 of the Labor Code,for the performance of the work for which this ` 6-/3
permit is issued. Owner or authorized agent: Dater
I 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 laws of California. If,after 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. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 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
GENERAL PERMIT APPLICATION �'LJ M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION U`
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 1
(408)777-3228•FAX(408)777-3333•buildingC&-cupertino.om MISCCUPERTIN
O 0PLUMBING ❑MECHANICAL ❑ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS rI 10�S� C'i F ({� � APN# n -7 O f
OWNER NAME L �( PHONE "1 E-MAIL
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STREET ADDRESS CITY,STATE,ZIP FAX
CONTACT NAME, C, PHONE ,5C
STREET
STREET ADDRESS LO Y-Ca,N O O Q! o r. CITY,STATE,ZIS,,/N yUCj�Cq, �j F�Y� 7Y-7-l---3-(-
❑OWNER 11OWNER-BUILDER 13 OWNER AGENT 'CONTRACTOR ❑CONTRACTOR AGENT/ ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME /(�� LI ELNS�U 2ER LICENSETYPE BUS.LIC#
COMPANY NAME J M i� E-MAIL FAX
STREET ADDRESS s� I r,✓8p CITY,STATE,ZIP J L� 5� g C P"6s � -
ARCHITECT/ENGINEER NAME LICENSE NUMBER / l BUS.LIC# GLS
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK �e c>J Mq(� Te/q C 1p�C-3 e,n C1 v del n� 2 w (,le_C,A L)J
Q� C�Pec�/T )j nt QGn
COT-
TOTAL
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TOTAL VALUATION: a G`b'.Q1,) 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. I have read this
application and the information I have provi ed 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 buildifid build' construction. I authorize representatives of Cupertino to enter theLaboyt-.0entified property for inspection purposes.
Signature of Applicant/Agent. Date:/ ll 3 V
SUPPI.M159TA L INFORMATION REQUIRED OFFICE USE ONLY
W ❑ OVER-THE-COUNTER
❑ EXPRESS
WV
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❑ LARGE
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❑_MAJOR
MEPMiscApp_201 1.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20387 clifden way DATE: 07/30/2013 REVIEWED BY: Mendez
i91APN: BP#: *VALUATION: 1$3,800
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS A
WORK � ro erty line clean out
SCOPE
j`,
11`14010 WIN-Iffsom
r , •
:L1ech. Pian Check Plumb.Plan Check 0.0 hrs $0.00 Dec.Plan Check
Llecft.Perruit Fee: Plumb.Permit Fee: IPPERMIT Laec.Permit l,ee:
other,heel. Insp. Other Plumb Insp. 0.0 hrs $47.00 Other Dec-Insp.
Adech.Insp. fere: Plumb. tusk.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn7 info,
FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Plumbing
Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $24.00 IPRSEWER Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: __F_T $47.00
Conswuction Tar:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes (2) No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure
i
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
MAN
�.-" 12
$139.50 $24.00 $163.50
Revised: 07/0.1/2013