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12010072 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 868 S STELLING RD CONTRACTOR:TATS INC DBA MR PERMIT NO: 12010072
ROOTER PLUMBING
OWNER'S NAME: BLAIS ROBERT A AND NAOMI S 44777 S GRIMMER BLVD STE C DATE ISSUED:01/10/2012
OWNER'S PHONE: 4089126101 FREMONT,CA 94538 PHONE NO:(408)271-2822
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class —3 Lic.#
MECH r- RESIDENTIAL� COMMERCIAL
Contractor (A VVI t'A" Date of l
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SEWER REPLACEMENT AND CLEAN OUT
(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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$6000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35922009.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and to that the above information is
correct.1 agree to comply with al city and ou ty ordinances and state laws relating
to building construction,and h by
al
ize epresentatives of this city to enter PERMIT EXPIRES IF WORK IS NOT ST TED
upon the above mentioned pr erty for' spec ion purposes. (We)agree to save
indemnify and keep harmle the City f Cu rtino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT IS N EOR
costs,and expenses whic ay accru agai t said City in consequence of the 180 DAYS FROM LAST CAL D
rD1S ION.
granting of this permit. A itionally the plic n tands and will comply �y
with all non-point so ce r ul e C Mum i al Code,Section {
P g P
9.18. Issued b r t
Signature Datell
r'
❑ OWNER-BUILDER DECLARATION rya nam RE-ROOFS:
All roofs shall be inspectii prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without)i�aining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safetyde,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cup ti Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Sectio 5je
( should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,sh I uipment or devices which emit hazardous air
contaminants fi the Bay Area Air Quality Management District I will
permit is issued. maintain co pli nee he CupertinoMunicipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health& fe Co e, 533,and 25534.
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 O or aut 1 !l
become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 1
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating 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,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35922009. 00
DATE ISSUED. . . . . . . : 01/10/2012
RECEIPT #. . . . . . . . . : BS000015720
REFERENCE ID # . . . 12010072
SITE ADDRESS . . . . . : 868 S STELLING RD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : BLAIS ROBERT A AND NAOMI S
ADDRESS . . . . . . . . . . : P 0 BOX 1386
CITY/STATE/ZIP . . . : CUPERTINO, CA 95015-1386
RECEIVED FROM . . . . : ADAM COLON
CONTRACTOR . . . . . . . : TATS INC LIC # 23496
COMPANY . . . . . . . . . . : TATS INC DBA MR ROOTER PLUMBIN
ADDRESS . . . . . . . . . . : 44777 S GRIMMER BLVD STE C
CITY/STATE/ZIP . . . : FREMONT, CA 94538
TELEPHONE . . . . . . . . : (408) 271-2822
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 .00 41.00 0 . 00 41.00 0. 00
1BCBSC VALUATION 6, 000 .00 1.00 0 . 00 1.00 0. 00
1BSEISMICR VALUATION 6, 000 .00 0.60 0. 00 0 .60 0. 00
1PPERMITFE FLAT RATE 1 .00 44.00 0. 00 44 .00 0. 00
1PRSEWER UNITS 1 .00 22.00 0. 00 22 .00 0. 00
1TRAVDOC FLAT RATE 1 .00 44.00 0. 00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 152.60 0. 00 152 .60 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 152 .60 VISA
---------------
TOTAL RECEIPT 152 .60
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 4b"76 - O PERMIT# d
OWNER'S NAME: no,O of 3 5 PHONE# qv-6 o ` 3 3
GENERAL CONTRACTOR: (p eo-Tjc,,r BUSINESS LICENSE#
ADDRESS: 1 I I IS - M QV/ CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city ave a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCU NCY the
C IONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL S O S HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. t J
I am not using any subcontractors: l 1
Signature 6ate
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum /Wood
Glass /Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting /Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock Z�Z/
Tile
i
wrier/Contr for Signature D e
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 868 s. stelling rd. DATE: 01/10/2012 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$6,000 - 1
'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPSS
USE: I I PERMIT TYPE:
WORK sewer replacement and clean out.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1 PRSEWER 1 # $22
TOTALS: $22.00
Plumb.Plan Check 0.0 hrs $0.00
_. Plumb.Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hrs $44.00
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the relinina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-0531ff 7'1./11) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $22.00
PME Permit Fee: $44.00
Administrative Fee: 1ADMIN $41.00
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRA VDOC $44.00 A
Stromy Motion Fee: IBSEISMICR $0.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.001 1
SUBTOTALS: $152.601 $0.00 TOTAL FEE: $152.60
Revised: 1/01/2012
1-2 6 c--�) t-� -7
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333• building(a)cupertino.org MISC
PROJECT ADDRESS P-T LUMBING ❑MECHANICAL ❑ELECT CAL [:]MISCELLANEOUS
OWNERNAME PHONE �� 2 (0 E-MAIL
STREET ADDRESS [� $ v�1 IJ.1 Crr.( STATE,ZIP ^ FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGEjr ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGwEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME n(� n LICENSE NUMBER LICENSE TYPE BUS.LIC# - G
COMPANY NAME 1k r ©(( / (U I E-MAIL FAX
STREETADDRESS( `�J- ` • n Ager 51 crTSTA E PPHONE
ARCHrrECTIENG _ R
WEENAME LICENSE NUMBER 1 BUS.LIC# 7 C1
COMPANY NAME' E-MAM FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WTI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO PLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the fol 'ng: I am th prop e owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided rrect.,I hav cCior1 of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating buil c on. I a orize r resentatives of Cupertino to enter the above'denn/tti1if d perry for inspection pu#poses.
Signature of Applicant/Agent: Date: V
UP EMENTAL INF ON REQ=D ,,/OFFICE USE ONLY
L7 OVER-THE-COUNTER
❑ EXPRESS
Y
U
S
❑ STANDARD
U
❑ LARGE
4
❑ MAJOR
MHPMIscApp 201 Ldoc revised 06121111