15090138 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10595 ORANGE TREE LN CONTRACTOR:LA ROCA BUILDERS PERMIT NO: 15090138
OWNER'S NAME: SHERMAN RICHARD J AND MARY W 3465 CHARING CROSS LN DATE ISSUED:09/21/2015
OWNER'S PHONE: 4082554671 SAN JOSE,CA 95132 PHONE NO:(408)835-5160
53 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
License ClassREPLACE(E)MAIN WATER LINE WITH(N)-LENGTH 15'
A Lic.# U( a7 Z? 9
Contractor `-S.S-Z /► M� p
Date ( —
1 hereby affirm that 1 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.
Sq.Ft Floor Area: Valuation:$6000
1 hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-insure for Worker's %PN Number:31634008.00 (h([I pa ncc T%Pc:
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
sb 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSP C ION.
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 Issued by: " " Date: '
upon the above mentioned property for inspection purposes. (We)agree to save
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 with RE-ROOFS:
all non-point so re lations per the Cupertino Municipal Code,Section 9.18. 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
Signature Date ^ inspection.
Signature of Applicant: Date:
❑ OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 1,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
2. 1,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will
1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the Health&Safety Code,Sections 25505,25533,and 25534.
performance of the work for which this permit is issued. ON ner or aja rized agent: _
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by Date: 2 ��
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. CONSTRUCTION LENDING AGENCY
3. I certify that in the performance of the work for which this permit is issued,l shall
not employ any person in any manner so as to become subject to the Worker's 1 hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If,after making this certificate of exemption,I for which this permit is issued(Sec.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name
must forthwith comply with such provisions or this permit shall be deemed Lender's Address
revoked.
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my plans shall be used as public records.
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 Licensed Professional
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
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 with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
GENERAL PERMIT APPLICATION M- - E
J CON1✓UNITY DEVELOPI✓ENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CU P E RTI N O (408)777-3228 - FAX(408)777-3333• buiIdlnO(5CUDer1,Inc.Orq 15
Mir
PLUMING ❑MECHANICAL []ELECTRICAL ❑MISCELLANE0US
PROIECfADDRESS
s-/ r0� ` Lwot I APNx
OWNERNAME ! t/ E-1✓L ,
Ct J' RI C�^�►-i/ PHO?\ _- �S - L(&-7 a�
STREET AMDRESS CITY, STATE,ZIP
CONTACT NAME f ^` PHONE Qa �7�5 _ �y r„ E-% IL
✓l � 1 W
STREETADDRESS
DDRESS / T C / j_l r CITY,STAT P Q /� A FAX
❑ OWNER ❑ OW1.'ER-BummER ❑ Ow..,ERA=N-r U CONTRACTOR ❑CONTRACTOR AGENT l❑I,ARC=ECT ❑ EtiGAreR ❑ DLlvEIAPER ❑ TE!:<',-
CONTRACTORR NAJ\M LICENSE!Z7G LICENSE TYPE BUS.LIC#
COMPANY N.A]✓E l r E-MAIL L FAX
STREET ADDRESS CI SATE,ZIP H
6 CIIartn ro5) Cie r(3
.ARCMTECT/ENGL\EER NAME —7—LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL I FAY,
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD o DUPLEX ❑ MULTI-FA1 OLY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ }'E$
BL=1*10: ❑COIAMMCLAL URBAN IN'T'ERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLERHOME7 ❑ NO
DESCRIPTION OF WORK ( ,
TOTAL VALUATION:
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 infonnation 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 building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signal=of ApplicaLUAgent: Date:
SUN' E . TAL INFORIv1ATION REQUIRED
F_XPRF5
-MEPMiscApp_2011.doc revised 06121/11
CITY OF CUPERTINO I5offD)y
FEE ESTIMATOR - BUILDING DIVISION
-TI
DDRESS: 10595 Orange Tree Ln. DATE: 09/21/2015 REVIEWED BY: Paul
P 316 34 008 BP#: 'VALUATION: 1$6,000
%PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPWS
USE: I I PERMIT TYPE:
WORK Replace E main water line with N - Length 15'
SCOPE
APPLIANCE/ EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1BPWSVCS 1 # $25
TOTALS: $25.00
Plumb.Plan Check 0.0 hrs $0.00
Plumb. Permit Fee: IPPERMIT
Other Plumb Insp. EE]�hrs $48.00 Li
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 preliminarl information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolwion I1-033 a.' 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check 1.cc
,S'u/,hl. PC Fee
PME Plan Check: $0.00
Per mi[ Fee.
Suppl. lu,%/r P ec
PME Unit Fee: $25.00
PME Permit Fee: $48.00
C'url.,[rucviun 7'cr.x:
Administrative Fee: (ADMIN $45.00
Work Without Permit? O Yes 0 No $0.00
IC/1r(rn t"I1 res:
Travel Documentation Fee: ITRA VDOC $48.00
Strong: Motion Fee: IBSEISMICR $0.78 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $167.78 $0.00 TOTAL FEE: $167.78
Revised'. 07/02/2015