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12100124 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10326 WESTACRES DR CONI'RACI'OR:GENMOR PLUMBING 1'ERMI'T NO: 12100124 OWNER'S NAIVE: VENTURA GLENN 1 ANIS DORO'T'HY M 2552 SEABOARD AVE DATE ISSUED: 10/162012 OWNER'S PHONE: 4089963006 SAN JOSE,CA 95131 PlIONE NO:(408)855-8348 C-NSED CONTRACT'OR'S DECLARA'T'ION .TOR DESCRIPTION: RESIDEN"FLU, COMMERCIAL ` r^ Lic�ense Class U I Lic.d n G(9 II INSTALL PROPERTY LINE CLEAN OUT Contractor Date `� herebyaffirm t um licensed under rhe provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business S Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following mo 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.FI Floor Area: Valuation:$7360 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 \PN Number.35914019.00 Occupancy'I'ype: permit is issued. API'I,ICAN'1'CER'I'IFIC,\']'ION I certify that 1 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 mid state laws relating WITHIN 1DAYS OF PERMIT ISSUANCE OR to building construclion,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY, 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 the ,w' �OJ4 Q granting of this permit. Additionally,the applicant understands and will comply Issued by: wL Date: �� with all n =poi on a regulations per the Cupertino Municipal Code,Section �� 9.18. RE-Roofs: Signature Date ` " I\% t/ 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 1 hereby affirm That I am exempt from the Contractor's License Loa for one of Signature of Applicant: Date: the fallmving two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages,is their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business R Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ileallh&Safety Code,Sections 25505.25533,and 25534. I will hereby affirm under penalty of perjury one of the following Three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Ileallh S Safely 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 1 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 Arca Air Quality Management District performance of the work for which this permit is issued will maintain compliance 1hertintiMunicipal Code.Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Ileallh S Safety'Code, .25533,and 25534.Section 3700of the LaborCode,for doe performance of the work for which this permit is issued. Owner or authorized agenDate: 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,alter making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must 1 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 1 have read this application mid state that the above information is correct. I agree to comply with all city mid county ordinances and state Imes relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(Wc)agree to save .\RCIII'I'ECI"S DECLARATION 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 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10326 WEST ACRES DA'L'E: 10/16/2012 REVIE\VED Bl': SYLVIA APN: BP#: *VALUATION: $7,360 *PERMITTYPE: Building Permit PLAN CII ECR Tl'PE: Alteration I Repair PRINIARI' SFD or Duplex PENTAMATION 1RPSS USE: PERMIT TYPE: Al WORK PROPERTY LINE CLEAN OUT SCOPE Mech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Flee.Plan Chock ,Mech.Peraut Fee: Plumb. Permit Fee: IPPERMIT Elec.Permit Fee: Other Afeeh. Insp. Other Plumb Insp. 0.0 hrs L$45.00 Other Elco boli. Ll I .1/ech.hup.Fee: Plumb. Msp.Fee: Flee.Inst).Fec: NOTE: This ertinmte doer not inch,dejeec due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District.School District, etc. . These feav are based nn the prefintinan information available and are only an ertinmte Contact the Dept for addn7 into. FEE ITEMS (Fee Resolmion 11-0531--ff. 7/1/171 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Plumbing Stipp]. PC Fee: 0 Reg. Q OT FO.OThrs $0.00 $23.00 IPRSE117ER I Sewer, Sanitary PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 1 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 Construction Tax: Administrative Fee: IADAIIN $42.00 Q Work Without Permit? Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential E) Travel Documentation Fee: ITRA I'DOC $45.00 Building or Structure i Strong Motion Fee: IBSEISMICR $0.74 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $133.741 $23.001 TOTAL FEE: $156.74 Revised: 10/01/2012 GENERAL PERMIT APPLICATION 121 M E r COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION , 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 \U A I CUPERTINO (408)777-3228• FAX(408)777-3333•buildinoQc cuoertino.org '\v/'\ v\ ❑PLUMBING []MECHANICAL ❑ELECTRICAL IO /I/7n SVV�utG/JI'✓U�`��l�/V�'G /Q,I IW — M-MIASICL ELvANI ElO US PROJECT ADDRESS 0�` ( AM, 1-1-4 OVNERNAMEGJ� o — E-MAIL 11REEi ADDRESS CITY, SrAT=5� FAX CONTACT NAME CI PHONE STREADDRESS ...��777'/y� �7✓/� C11-Y'CAM I Dal .1 FAX ❑ O� ❑ OWT///'��ER-BUZ'DER ❑ OWNER AGENT v❑1 CO `NTRAJ CrOR ❑CON tAA.mR AciNT ❑ ARCFCTER ❑ENcINEnz ❑ DEt SIo.PEY ❑ TENANT CONTRACTOR NAME61 SQA ,�^,(rJ�1 / LICENSE NUM�.y�9(4I LICcT'�£l BUS.LC# COMPANY NAME �l0 I Uf{I•'If✓I 1 1. E-MAIL // 'J FAX �) STREADDREYW- 1% ? d CA( ` I CTY PHON ARCHMzCT/FNGArlNAME LICENSE NLUNSER I BUS.LIC i COMPANY NAMEE-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF O SFD m DUPtFX EIMULTI-FAMD.Y PROSECTN wuDLAND M PROJECT IN E] FS YIS THE O ES BIRAN ❑ Y BUILDING: COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE el— r [I No EICHLEA HOME? ❑NO DEBCRUTION OF wORX eAI L . '� L�V)•VW�v� N Pel ��. I vrC^I TOTAL VALUATION: U _ I RECEIVED BY: By my signanre below,I certify to each of the following: I am the propery owner or authorized agent to act on the p p owner's behalf. I have rad this application aid the infonration I have provide 's ¢ t have read the Desciption of Work and verify it is accurate. I agree o compI with all applicable local ordinance and sate laws relating to bu' 0 ov 'on. I au;hosis:epreseatatives of Cupertino to enter the above-idcn•' p/roper, for inspecrio¢pdsoses. Signature of Applicant/Agenu Date: l SUPPLE INFORMATION REQUTRED OFFICE USE ONLY y ❑ OVER-THE-COUNTER _ ❑ EXPRESS u n ❑ STANDARD U ❑ LARGE ❑ NWOR MEPMae4pp_2011.doc revised 06/21/11 '