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13090170 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21164 GRENOLA DR CONTRACTOR:GREENBERG CLARK INC PERMIT NO:13090170 DBA THE OWNER'S NAME: XU LEE L AND WU MICHELLE M TRUSTE 600 BROADWAY STE C DATE ISSUED:09/23/2013 OWNER'S PHONE: 4085616885 SACRAMENTO,CA 95818 L.PHONE NO:(916)4554433 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALS License Class C Lic.# �� - INSTALL(N)TRENCHLESS SEWER LATERAL FROM FOUNDATION TO PROPERTY LINE,INSTALL 2(N) Contractor ` Date CLEANOUTS I hereby affirm that I am rcensed under the provisions of Chapter 9 NITARY (commencing with Section 7000)of Division 3 of the Business&Professions Ad"k A 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:$7500 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:32628058.00 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 DAYS 901ST 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 2 3 Iss granting of this permit. Additionally,the applicant understands and will comply with all non-point s ertino Municipal Code,Section 9.18. RE-ROOFS: Si Date All roofs shall be inspected prior to any roofing material being installed.If a roof is 5* 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(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,Sectionand 25534. Section 3700 of the Labor Code,for the performance of the work for which this 7 t Owner or authorized agent: Date: 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 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 O\ GENERAL PERMIT APPLICATION MEP 1-21 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC CUPRTINC (408)777-3228•FAX(408)777-3333•buildingna.cupertino.ord PLUMBING DmEcHANicAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS ` 7APN# r Zq OWNER NAME PHOrr�� �'0 E-MAIL 't0 STREET ADDRESS j a STATE,ZIP 45C AX�, CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX L C� ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBERLICENSE TYPE BUS.LIC# "ns-I b� `n 10 COMPANY NAME ( ilk MAIL FAX STREET ADDRESS ObQ CITY,STATE,ZIP PHONEscz t- (�S%_t 14l ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# �F COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WBALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? NO DESCRIPTION OF WORK c e TOTAL VALUATIO By my signature below,I certify to each of the following: I am the property owner or authorized agent to ac on the own a alf. I have read this application and the information I have provide is correct. I have read the Description of Work and verify it is accurate. I a ee to comply with all applicable local ordinances and state laws relatin s of Cupertino to enter the above-ide tified property for inspection purposes. Signature of Applican Date: S P MENTAL INFORMATION REQUIRED g� &--f "`` `�' � ,©FFICE USE ONii. W.m. JU� 'TD:�COUI!ITiEIY,�, k. ED P �iaNnaxn ti r y� I i " O MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21164 GRENOLA DR DATE: 09/23/2013 REVIEWED BY: MELISSA APN: 326 28 058 BP#: 'EVALUATION: 1$7,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: I I PERMIT TYPE: WORK INSTALL N TRENCHLESS SEWER LATERAL FROM FOUNDATION TO PROPERTY LINE SCOPE I INSTALL 2 (N) CLEANOUTS APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $24 TOTALS: _ ..> .. 1 $24.00 ,: •.� ., fre -°r`a'i'`.; '"j . ; Xlech. Plan(.heck Plumb.Plan Check 0.0 hrs $0.00 Elec—Plan Check ;L1ech.Permit Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit FCC. rCJther Alech.Insp, Other Plumb Insp. El hrs $47.00 Other Dec,Insp. Ajech.Insp.Fee: Plumb. Insp.Fee: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the prelinddha information available and are only an estimate Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plein Check Fee: Suppl. .P("Fee PME Plan Check: $0.00 Permit Fee: rSuppl Insp Pee PME Unit Fee: $24.00 PME Permit Fee: $47.00 Consli-tenon Tax: Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes (2) No $0.00 Advanced Planning Feer: Travel Documentation Fee: ITRAVDOC $47.00 A Strong Motion Fee: IBSEISMICR $0.75 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 1021mi'A"02", „'-_ $163.75$163.75 $0.00 a, �, Revised: 08/01/2013