15120095CITY OF CUPERTINO BUILDING- PERMIT
BUILDING ADDRESS: 21740 RAINBOW DR
PER IT NO: 15120095
CONTRACTOR: T�
/)�
BETE ED
OWNER'S NAME: VIRAY PROPERTIES LLC
DATE ISSUED: 12/10/2015
OWNER'S PHONE: 4089048614
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
1
INSTALLATION OF GRINDER PUMP STATION.
License Class VD Lic. #�
Contractor 4_„ AQ/\Date f Z -A o
I hereby affirm that I amLicensed nder 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: $5000
perform the work for which this permit is issued.
I 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 is issued.
APN Number: 36603063.00
Occupancy Type:
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 INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of thej
Issued by: Date: 1 3
granting of this permit. Additionally, the applicant understands and will comply
_O a
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
l
�<L
RE -ROOFS:
Signature 1' -- — -ate 1 \ `
A11 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 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 Say 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, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which thisOwner
or authorized agents --1 .--- — — 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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
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 APPLICATIONMEP
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`'� COMMUNITY DEVELOPKAENT DEPARTMENT • BUILDING DIVISION
10300 T ORRE AVENUE CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • buildina(a ouoeriino.org J
CUPERTIiiiO M Ir
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FAX
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OtitNM ❑ OM ER -BUILDER ❑ OFI?,-,mAGEI,'T ❑ CON-rpukCTOR ❑ CO\7RACTORAGMZT ❑ ARC3iiECT 91-NGL\z"_R ❑ D_EVELOPER ❑-fEK',j,-r
CONITRACTOR N -AJ M - r t I LICEI.SE NUbMER I LICERSE TYPE
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ARCIRTECT/ENGNEER NAA,£ ( LICENSE 1,%W,BER
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ?11SFD or DUPLEX ❑ UL TI-FAIMLY . PROJECT LN R'II.DLF1vTD ❑ YS PROJECrN ❑ YES
tS =BLDG X ❑ YES
B u-ZDNIG: ❑ COI&A-MCIAL I URBAN IlQTERFACE AREA 'O FLOOD ZONZB O
( MCHLER HOLE? 19NO
DESCMPTION OF WORK
TOTALVALU.ATIOhr: "v' i ECEIiEDBI NNI _� .. ..
By my signature below, I certify to each of the following: am the pr erty ower or authorized agentto act on the property owner's behalf. I have read this
application and the information I have provided is correc . I have read" e Dess tion of Work and verify it is accurate. I agree to comply with all applicable local
to building `' . I autho ' representR sof Cup --Lino to enter `,he above-iydeutifi d prop qty for inspection purposes.
ordinances and state laws relating constru -
Si�ature of?.pplicanJAgent: ' Date: F
SU-PPLEAIENTTALD\TFORMATION REQUIRED �o cE sEo� x
AfEPA/isc,App_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21740 Rainbow Dr DATE: 12/10/2015 REVIEWED BY: Sean
APN: BP#s VALUATION: $5,000
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFDor Duplex PENTAMATION 1 RPGT
rreU. p PERMIT TYPE:
WORK
SCOPE
station
Revised` 10/01/2015
Plumb. Plan Check
0.0
hrs $0.00
Plumb. Permit Fee: IPPERMIT
Other Plumb Insp.
1.0
hrs
$48.00
Plumb. Insp. Fee: IPLMBINSP $143.00
< `
to other Departments (i. e.'Planning, Public Works, Fire, Sanitary Sewer District, School
11
does include fees due
NOTE. This estimate not info.
District, etc.. These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn
FEE ITEMS (Fee Resolution 11-053 E . 7/11131
FEE
QTY/FEE
MISC ITEMS
Sf p 1l P(."'.Fee
PME Plan Check:
$0.00
rAAJi'i"mil i € e
PME Unit Fee:
$36.00
PME Permit Fee:
$191.00
Administrative Fee:
IADMIN
$45.00
Work Without Permit?
0 Yes (E) No
$0.00
Travel Documentation Fee:
ITRA VDOC
$48.00
$0.65
Select an Administrative Item
Strong Motion Fee:
IBSEISMICR
Bldg Stds Commission Fee
IBCBSC
$1.00
:=STIBToAL i°
$321.65
$0.00
iLTAL FEE_
; $321.65
Revised` 10/01/2015