14010153CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10810 PENINSULAR AVE
CONTRACTOR: ABLE SEPTIC
PERMIT NO: 14010153
OWNER'S NAME:
SAN JOSE, CA 95154
PHONE NO: (408)377-9990
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
❑ LICENSED CONTRACTOR'S DECLARATION
C_ L Z Lic. # �77 % 7�
PROPERTY LINE CLEAN OUT
License Class
Contractor 6_ 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.
I 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: $3500
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 32603047.00
Occupancy Type:
ection 3700 of the Labor Code, for the performance of the work for which this
ermit 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 DAYS FR AS ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
City in of the
ry
costs, and expenses which may accrue against said consequence
Issued by: Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
918.
RE -ROOFS:
Signature Date
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:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
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
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
for this
the Health & Safety Code,
permit is issued.
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code, must
work's for which this permit is issued (Sec. 3097, Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked.
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
918.
Signature Date
GENERAL PERMIT APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 6�0 amm I S C
(408) 777-3228 • FAX (408) 777-3333 • building 5cuoertino.org Ao1
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PROJECT ADDRESS l ng o noinjv/av a, f
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AP" 32 -Lo 03 64-76(i
OWNZERNAME /
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STREET ADDRESS Q / �y ?% o1N�U/A v
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CITY, ST
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CONTACT NAME / J(/ L
PHONE ' �YJ_'J� ,7-5111,9 E-MAIL
STR£ETADDRESS
CrrY.STATX
FAX
❑ OWNER ❑ OWNER-BUMDER ❑ OVTNERAGENT
CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMELICENSE
�.77s
NUMBER
LICENSE TYPE
BUS. LIC #
672 q-75
COMPANY NAME ^ )SG
f Y I
E-MAIL
FAX
STREET ADDRESS % �/
CITY, S ZIP
,y
L <
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
B -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD .,DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL -
PROJECT 1 tLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT AT ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN YES
EICHLER HOME? ❑ NO -
DF -SCR IPTIONOFWORK
TOTAL VALUATION:
•-uft-
�Y
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on t roperty o is behalf. I have read this
application and the information I have provided is correct, ve read the Description of Work and verify itis accura I agree to omply with all applicable local
ordinances and state laws relating to build' onstructi uthorize representatives of Cupertino to enter the above-/iden 1 ope for inspection purposes.
Signature of Applicant/Agent: ' Date: / I) -
)-SUPPLED
SUPPLE INFORMATION REQUIRED
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SSTA3��;:
MEPMiscApp_2011.doc revised 06/21/11
W��,�,,�ON�� CITY OF CUPERTINO
IRV11? F:CTI<MATnR — RITILDING DIVISION
iiADDRESS:
10810 peninsular
QTY/FEE
DATE: 01/28/2014
REVIEWED BY: Sean
APN:
BP#:
"VALUATION: 1$3,500
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
SFD or Duplex
PENTAMATION
1 RPSS
USE:
$0.00
PERMIT TYPE: i
WORK
ro ert line clean out
Permit Fee: Hourly Only? 0 Yes (D No
$0.00
Suppl. Insp. Fee -0 Reg. ® OT
0.0 1
SCOPE
$0.00
Mech. Flan Check I I I Plumb. Plan Check 0.0 1 hrs $0.00 Dec. Plan (."heck
;Lfech. Permit Fee; I Plumb. Permit Fee: 1PPERMIT Flec. Permit Fee:
Other Alech. Insp. I I I I Other Plumb Insp. 10.0 I hrs I $47.00 I Other Flee. Insp.
Aleeh. Insp. Fee: I Plumb. Insp. Fee: I Flee. Insp. Fee:
NOTE. This estimate does not include fees due to other Departments (ie. Planning, Punac works, rlre, aamrary newer uturlct, acnuul
..I:—J*---.:w! .. si..w ..-.I-1./n nwd Ora ns Ar nn octimatn. rantart thv AOnt for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 711/132
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F 17 # Plumbing
$24.00 IPRSEWER Sewer, Sanitary
Suppl. PC Fee: 0 Reg. 0 OT
0.0 Ihrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? 0 Yes (D No
$0.00
Suppl. Insp. Fee -0 Reg. ® OT
0.0 1
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$47.00
Consiruction Tax.
y r
Mech. Flan Check I I I Plumb. Plan Check 0.0 1 hrs $0.00 Dec. Plan (."heck
;Lfech. Permit Fee; I Plumb. Permit Fee: 1PPERMIT Flec. Permit Fee:
Other Alech. Insp. I I I I Other Plumb Insp. 10.0 I hrs I $47.00 I Other Flee. Insp.
Aleeh. Insp. Fee: I Plumb. Insp. Fee: I Flee. Insp. Fee:
NOTE. This estimate does not include fees due to other Departments (ie. Planning, Punac works, rlre, aamrary newer uturlct, acnuul
..I:—J*---.:w! .. si..w ..-.I-1./n nwd Ora ns Ar nn octimatn. rantart thv AOnt for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 711/132
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F 17 # Plumbing
$24.00 IPRSEWER Sewer, Sanitary
Suppl. PC Fee: 0 Reg. 0 OT
0.0 Ihrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? 0 Yes (D No
$0.00
Suppl. Insp. Fee -0 Reg. ® OT
0.0 1
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$47.00
Consiruction Tax.
Administrative Fee:
IADMIN
$44.00
E)
Work Without Permit? ® Yes (E) No
$0.00
Advanced Planning Fee.
$0.00
I�v J hours
$0.00
Inspections
Inspection, Hourly
E)
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion Fee:
1BSEISMICR
$0.50
F-61 # Revisions
$0.00 IREVSFDWL SFDWL
Bldg Stds Commission Fee: IBCBSC
$1.00
$139.50
$24.00
=TOy a
$163.50
Revised: 01/15/2014