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14090136 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19260 TILSON AVE CONTRACTOR:ABLE SEPTIC PERMIT NO: 14090136 OWNER'S NAME: CAROL MOON TRUSTEE P O BOX 24819 DATE ISSUED:09/22/2014 OWNER'S PHONE: 4084238000 SAN JOSE,CA 95154 PHONE NO:(408)377-9990 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E] WATER LINE REPLACEMENT License Class C y2 Lic.# -�'*-7 677q7-57 Contractor Abet Date L 2Z 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:$2400 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:37540055 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 1 AYS F 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 OM LAST 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 `/,22.14 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations the Cupertino Municipal Code,Section 9 18. RE-ROOFS: Signature Date s Z 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 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, 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,Sectio 5505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dater 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 GENERAL PERMIT APPLICATION LP MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �\0 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 �a (408) 777-3228•FAX(408)777-3333•buildingCaD_cupertino.org MISC GUp`��t`t`tN0 \ 5OLUMBING []MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS tg2b 1S��n o�V� C� e��r V�p JAPN" x-75 fU C�SS,CP OWNER t;AME % u Lrh �Yo erg- Car�v PHONE �Z3 �D��O STREET ADDRESS (xcN CITY, STATE,ZIP_ ` I FAX �2o I M CONTACT NAME P Ub Lk-Q,-1�,Wo 1. Sa WCS�CVN Y� e� r� Ca1h STREET ADDRESS CITY,STATE,ZIP FAX ❑ OWNER -❑ ORT7ER_BUJDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGn\EER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME, LICENSENUNSB LiCe\5 � BUS.ZLIC a coMPAJaY ISA , -T,..,_ se YI TRV` E MAII CUYF �lC{Z•t CX�rU STREET ADDRESS �Y� CITY,STATE,ZIP PHONE 9wN x5110 C q b ARCHTTEMENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULM-FAMILY PROJECT IN V DLAND ❑ YES .PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUJI DING: ❑COMMERCIAL URBAN INTTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO DES CRIP ON OF WORK q \ l� voy ry RECEIAEDBi TOTAL VALUATION: �yOV•� �r�•` ,a��.`sr '��- ��'�= ,��.,_ ".•�:,"-s=' ��+'.-_ ,� war`--� By my signature below,I certify to each of the following: I 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 provided is correct. I 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 b ' n onstruction. IpeVrize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENT ORMATION REQUIRED OFFIGE37SEY31�S 0 • '�#�'ERTHEC-{3LZ93ER �` -' u 00-41 v '' - �.� t�3.ARGE '� -,�'� •. MR N 1? r-" -_ MEPMiscApp_201 Ldoc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 19260 TILSON AVE DATE: 09/22/2014 REVIEWED BY: MENDEZ APN: BP#: *VALUATION: 1$2,400 *'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 RPRP USE: p PERMIT TYPE: WORK WATERLINE REPLACEMENT SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Re-Pipe Interior 1PRREPIPE 1 # $14 oi TOTALS: a $14.00 r ,414 a .ta�Jkir c,eE'>r4.;II'Plsar�l . Plumb..ZPlan Check wct, Petwit Fee: Plum Icch ImPftherPlumb IPP$E$4R08M..00I0T0 1o>lmece.r.l'ifri�R.t1_`rz�sp1cS,, Fee: l s � e Fee: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelimina information available and are onl an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS Plun Check �.., stiffpl PC F''(' PME Plan Check: $0.00 Perinil t .qtr dal. In p I lee PME Unit Fee: $14.00 PME Permit Fee: $48.00 Consirvclion Tax: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes No $0.00 is/3'fI32L.`t'.d Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 i Strong;Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldy,Stds Commission Fee: IBCBSC $1.00 a $156.50 $0.00 TOTAL FEE: $156.50 Revised: 08/20/2014