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15120183CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7442 STANFORD PL CONTRACTOR: AMERICAN PERMIT NO: 15120183 RESIDENTIAL SERVICES OF CA OWNER'S NAME: CHEN FRANK T AND ANNE F 965 RIDGE LAKE BLVD STE 201 DATE ISSUED: 12/22/2015 OWNER'S PHONE: 6506653299 MEMPHIS, TN 38120 PHONE NO: (408) 982-0405 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL INSTALL (N) 2 WAY BUILDING CLEANOUT **CUPERTINO License Class �CcC?_ n Lie. # b�I S__S SANITARY** c� �� �.�����°e Contractor ate 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 Sq. Ft Floor Area: Valuation: $2200 performance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by ection 3700 of the Labor Code, for the performance of the work for which this APN Number: 35932021.00 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 FROM LAST CALLED INSPECTI N. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the �j rG`�.( . " ,� V Issued by: 7 1�' �— Date: granting of this permit. Additionally, the applicant understands and will comply with all non-pgt source regulations per the Cupertino Municipal Code, Section 9.18. Signatur Date 121 RE -ROOFS: 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 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the stricture 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, Sect*. ns 25505, 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 15/091) 183 COMMUNITY DEVELOP10ENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 3255 (408) 777-3228 • FAX (!08) 777-3333 - build! n0(d)CUDer inO.Org CU FE RT ItoI Luv2NG ❑ l EC1-T-kN7CAL ❑ ELECTRICAL ❑ i, czl-L.A,N-OUS PROT-nCT .aDDPESS , _ . � E - I .SP?\ PHO. E-1Ji1 IL -2- '� � COG STR ET: DDRES� Lt Z CAF: X `/ I I CITY, STATE, Zip !� Q� -�! al {/ F� CONT.kcT NA ✓E PHO;IBM E-1✓�aIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ 0' R ❑ 01ATy?-3U Ti D ❑ Oti'Am-R AG ---,,T ❑ coNIP ACTOR ❑ CONTRACTOR AGENT ❑ -4RC LEECT ❑ ENGINEER ❑ DEVELOPER ❑ i` ��-( CONTRACTOR NAJ,r- LICE NSE NUI BER LICENSE TYPE BUS. LIC 1 C01112ANY NA1a�" �.S �-'ie E-MAIL FAX 4 KD . {L 0 Y S c f e -S STREET A..DDRESS CITY, STATE, Zip PHO - .RCMTECTrNGIXEER NAME LICENSE NU? MER BUS. LIC COMPANY KLIvZt: I E-I✓L1.IL. I FAD', STREET ADDR SS I CITY, STATE, ZIP I PHONE USE OF ❑ SFD or DUPLEX ❑ i ruLTI-F.aA,zLY . PROJECT LN WILDLAND ❑ YES PROi-LCT IN ❑ Y -Es IS TF--- BLDG AN ❑ ti':s BL-3-7DLNIG:❑CO12,=- ,CLAr UR3LND\=1- F.CEA-Pak ❑ NO F?OODZONE ❑ NO HICH ERE{OM-2? ElNO I DESCRIPTION OF IVORK L/V\ +uo ���lv✓ l (��LJ TOTAL VALUATION ION: Z 2 UC�) REC�II�D Ba X 4 1 �u N C h� 3 h M r By my signature below, I certify to each of the following: Ian the prope.--ty owner or authorized agent to act on theope. owner's behalf. I have rend this application and the , formation I .�av_e 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 Iaws relate g'to building co ction. I authorize representatives of Cupertino to enter the above -idea ified proper r for inspection purposes. Si—�ature ofA.oplicant/Agent: f Date: 2— Z T fE i^ 7F T t T' — SUPP_E?���� ENTAL L�rOR✓rATIOI� REQLLRrD OtiER'TOL�TER A11'ET ,7SC, D,p_2011.doc remised 06/21/11 CITY OF CUPERTINO 15190193 W -W FEE ESTIMATOR -BUILDING DIVISION W-ADDRESS: 7442 Stanford Place Plumb. Plan Check 0.0 1 hrs $0.00 DATE: 12/2212015 REVIEWED BY: PAUL 6, APN: 59 32 021 I BP#: *VALUATION: 1$2,200 *PERMIT TYPE: Plumbing Permit F-1 PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: PME Plan Check: PENTAMATION 1 RPSS PERMIT TYPE: WORK Install (N) 2 Way Building Cleanout "Cupertino Sanitary" SCOPE Suyy.�L Mx'b. I'lan ('.'beck Plumb. Plan Check 0.0 1 hrs $0.00 1lec, Plan Chec'^�C I I ee" Plumb. Permit Fee: IPPERMIT Pe 4f P'ee. Other Plumb Insp. 0.0 hrs F-1 PME Plan Check: DOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, Schooi District, etc.). Theselees are based on the preliminary information available and are only an estimate. (,'ontact ineuept,for aaan't info. FEE ITEMS (Fee Resolution 11-053 Eff,' 711113 FEE QTY/FEE MISC ITEMS pLyn "heck 1,"ee" ( SnppL P(T.Fee F-1 PME Plan Check: $0.00 Suyy.�L PME Unit Fee: $25.00 PNM Permit Fee: $48.00 ("Onsiruction 711x: Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (D No $0.00 Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 . .. .. $167 SUBTOTALS .50 $167.50 $0.00 --TOTALTEE:f:� Revised: 10/01/201!