14010020 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6031 BOLLINGER RD CONTRACTOR:TATS INC DBA MR PERMIT NO:14010020
ROOTER PLUMBING
OWNER'S NAME: ANN NG 1260 YARD CT DATE ISSUED:01/06/2014
OWNER'S PHONE: 4085096538 SAN JOSE,CA 95133 PHONE NO:(408)271-2822
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
�7 INSTALL(N)PROPERTY LINE CLEANOUT
License ClassC Lic`.# k? Z
Contractor /tom!/! Date L
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions SAN
Code and that my license is in full force and effect. I rAR
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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3200
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 APN Number:37538003.00 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 18 O + �RMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enterupon the above mentioned property for inspection purposes. (We)agree to save 180 FRO S CLLED 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
granting of this permit. Additionally,the applicant understands and will comply Date:
with all non-point source regulations per the Cupertino Municipal Code,Secti n
918.
RE-ROOFS:
Signature (i' -- Date +fo" L 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 contractif►g 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(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 by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date:
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
918.
Signature Date
_ GENERAL PERMIT APPLICATION EP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O
t�
10300 TORRE AVENUE CUPERTINO,CA 95014-3255 UMEN
(408)777-3228•FAX(408)777-3333•building-) _qI S C
�UP��`1"tNd
PLUMBING ❑MECHANICAL ❑ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS �^ 1 -3APN# r - - Q O 3
L/ J
OWI,TER NAME PHONE -MAIL
STREET ADDRESS c7 CITY, STATE,ZIP rG�L FAX
CONTACT NAME PHO E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER BUILDER ❑ OVVNERAGENT CONTRACTOR ❑COATMACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME 'n LIC E ER LICENSE TYPE BUS.LIC#
Ir
COMPANY NAME ]fE-MAIL FAX
n 2,C'u
STREET ADDRESS CrrY,STATE,ZIP fn PHONE
17
ARCHrrECT/ENGINEERNAME LICENSE NUMBER Yom- BUS.LIC#
COMPANY NAME EMAIL FAX
STREET ADDRESS C=,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMMY PROJECT IN V=L AND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: F1COMMERCIAL URBAN I iTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK 4
/ (ti Vim. 6�-
Y --
_ �,
TOTAL VALUATION: E- - _ mat, „ W �"�,`
t ,s s�"-^n ' fir« cam.'`'. y _
By my signature below,I certify to each of the following: I am the property owner or authorized agent to ac n the pr q 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 vrith all applicable local
ordinances and state laws relating to building co ction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED z dF cEIs>n s
' � R THE CO_IINTER _ f1
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 6031 BOLLINGER RD DATE: 01/06/2014 REVIEWED BY: MELISSA
APN: 375 38 003 BP#: *VALUATION: $3,200
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS i
WORK INSTALL N PROPERTY LINE CLEANOUT
SCOPE
APPLIANCE/EQUIP TYPE FEE II) QTY UNITS BP FEES
Sewer,Sanitary 1PRSEWER 1 # $24
TOTALS: n $24.00 t w
��Id4
n9 0 _ a `{^
.Meeh.-Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec..Plan Check
rL1e1
%.Permit Fee: Plumb.Permit Fee: IPPERAfIT Elec. Permit Fee:
Other Ue{ch.IMP. Other Plumb Insp. 0.0 hrs $47.00 Other Elec,Insp.
11ech.Insp.Fee: Ml wb. hrsp.Fee: Elee.Inch,I,ee:
NOTE:This estimate does'not include fees due to other Departments(i.e Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the preffinWha information available and are only an estimate Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS
Plan CheckFee:
suppl. PC'Fee
PME Plan Check:. $0.00
Permit.Fee:
Suppl. Ins[)Fee
PME Unit Fee: $24.00
PME Permit Fee: $47.00
Conslruc:tion Tax: T-F
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes (E) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldp_Stds Commission Fee: IBCBSC $1.00
:�fl p G $163.50 $0.00 rs 0 $163.50
m
Revised: 10/01/2013