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11090178 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1095 MILKY WAY CONTRACTOR:TATS INC DBA MR PERMIT NO: 11090178 ROOTER PLUMBING OWNER'S NAME: KOO KWOK K 44777 S GRIMMER BLVD STE C DATE ISSUED:09/23/2011 'NER'S PHONE: 4082539676 FREMONT,CA 94538 PHONE NO:(408)271-2822 4J LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT F PLUMB License Class �U Lic.# A7(-)' r MECH RESIDENTIAL COMMERCIAL Contractor AT I hereby affirm that am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL NEW PROPERTY SEWER LINE AND ADD 2 NEW (commencing with Section 7000)of Division 3 of the Business&Professions CLEANOUTS Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 1 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 y 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: aluation:$3500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION APN Number:362190 Occupancy Type: '-� 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 PERMIT RES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this it. Additionally,the applicant understands and will comply with all non- nt source reg tions per the Cupertino Municipal Code,Section 9.18. Issued by:' -"Z-- Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected 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 first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) I,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 declarations: HAZARDOUS MATERIALS DISCLOSURE 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&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Saf;iaS�/ ons 25505,25533,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 Owner or a ,��become subject to the Worker's Compensation provisions of the Labor Code,I must Date 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 cork'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 iaPmnify and keep harmless the City of Cupertino against liabilities,judgments, ,and expenses which may accrue against said City in consequence of the L ling of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION 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 . . . . . . . . : 36219007. 00 DATE ISSUED. . . . . . . : 09/23/2011 RECEIPT #. . . . . . . . . : BS000014854 REFERENCE ID # . . . : 11090178 SITE ADDRESS . . . . . : 1095 MILKY WAY SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . KOO KWOK K ADDRESS . . . . . . . . . . : 1095 MILKY WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : FRANCISCO ORELLANO 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 3, 500 .00 1. 00 0. 00 1 . 00 0 . 00 1BSEISMICR VALUATION 3, 500 .00 0 . 50 0. 00 0 .50 0. 00 1PPERMITFE FLAT RATE 1 . 00 44 . 00 0. 00 44 . 00 0. 00 1PRSEWER UNITS 2 . 00 44 . 00 0. 00 44 . 00 0. 00 1TRAVDOC FLAT RATE 1. 00 44 . 00 0. 00 44 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 174 . 50 0 . 00 174 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 174 .50 MC --------------- TOTAL RECEIPT 174 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING i 7(P GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• buildinq(q�cupertino.orq MISC CUPERTINO -/5LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS �7 6 D D 2 �. OWNER NAME PH .+1 /� �J�7� E-MAIL STREET ADDRESS �� WAY M C STA �f ' �� a FAX CONTACT NAME vl/�`) u 04 L ' o - -7 3 �jc. . STREET <gnZy -7 , A. �&FAX ❑OWNER ❑ OWNER-BUILDER `�-❑ OWNERAGEENT/ ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHTI•ECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR LICENSE LICENSE TYPt BcL� # COMPANY NAME E-MAIL FAX (! STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROTECT IN WI DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK ,:�-x / "-,.A &�J 1 4 ! c.G T )2 c .S TOTAL VALUATION: RECEIVED BY: C� By my signature below c ✓✓✓ to each of th following: 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 prow' ed is come 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 buil �n n`I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 7 ,L7— ,1-1/ S AL ORMATION REQUIRED OFFICE USE ONLY VER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD U U < ❑ LARGE a ❑ MAJOR 11EPMiscApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 1095 milky way DATE: 09/23/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $3,500 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK install new property sewer line add 2 new cleanouts. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 2 # $44 TOTALS: $44.00 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 Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.). Thesefees are based on the preliminary in ormalion available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (I ee Resolution 11-053 F_jf T'h'11 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? Q Yes E) No $0.00 Travel Documentation Fee: 1TRAVDOC $44.00 Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50 Revised: 09/02/2011 Building Department City Of Cupertino L21 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: yb PERMIT# OWNER'S NAME: PHONE# YG �- GENERAL CONTRACTOR: /2, BUSINESS LIC NSE# 3 ADDRESS: �. CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBC NTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: � �� gnature Date Please check applicable subcontractors and complete the following information: 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 000Plumbing Roo ng Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date