13010096 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20696 GREENLEAF.DR CONTRACTOR:JAMES CACCIA PERMIT NO: 13010096
PLUMBING INC
OWNER'S NAME:
SAN MATEO,CA 94401 PHONE NO:(650)342-5363
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: R D IAL COMMERCIAL
License Class e Lie.H 37 93 6 _ INSTALL NE ER LINE CLEANOUT
ContractorN6 N°C-e iati
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000).of Division 3 o the Business&Professions
Code and that my license is in full force and effect
1 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. . our Area: Valuation:$3288
I have and will maintain Worker's Compensation Insurance,as provided f
Section 3700 of the Labor Code,for the performance of the work for whic N Number:32633044.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION -
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 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 + LAS LED 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
granting of this permit. Additionally,the applicant understands and will comply Is by; Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
l RE-ROOFS:
Signature , DateAna� 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:
1 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). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 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(x)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 permitjs issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,w provided for by the Health&Safety Code,Section 505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent• Date:X/�/3
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 most 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 thatthe above information is
correct.1 agree to comply with all city and county ordinances and state laws relating
to building concoction,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 /� M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION q
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 \ D M I
CUIPERTINO (408)777-3228•FAX(408)777-3333•building(RIcupertino ora
Vm.UMBING EIMECHANICAL FLBCIRICAL MISCELLANEOUS
PROJGCI'AUURF:SS Zo(,X10 -�rze,n 1 1Jr 3 26 3 3 0 �y
APNq
SO�W[fN'1E,jR 9NA�MEfySI
`.Q I Y S • L
OA `7S / l FAX
CO "A AME ` PdN L.) 3qa- 3 E-MAIL
ST Iilil'ADDI�GSJS 1/�I /_ CIT STArIi,'LIP �� FAX
❑OWNER (❑ OWNER-BUILDER / ❑ OWNL'RA0ENT CONTRACI'0R ❑CONTRAC'rOKAGL'NI ❑ AitcturECI' ❑ENOINVER ❑ DEVELOPER ❑ 'I'FNANT
CON'RACI FAMIi 1VL LICENSENUMBEK jyQCpIS�'"TYPE .LIC ILS
COMPANY NAME E-MAIL `CLQ lO pl
FAX
I� L I 1/J/ ,I
S' 1`11 UORES' C S'FA•I'L'.% �� ql jIC)) PIONS 3I`-p
ARCIII'FECI'/ENGINF.ER NAME LICENSENUMBER BUS.LIC9 �
COMPANY NAME EMAIL
FAX
S'IREE-F ADDRESS CITY,STATE,ZIP
PHONE
USE OF ❑SFDor DUPLEX ❑ MULTI-PAMILY PROJECTINWILDLAND ❑ YES PROJECT IN ❑YES ISTIICBLUGAN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD%ONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
'I'O'1'AL VALUA'rtON' R
By my signature below,I certit to each of the following: I am the property owner or authorized agent to act on the property owner's a f 1 have read this
application and the information I have provided is comet. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatiinkiAlLuildingcoutructiop. I authorize representatives of Cupertino to enter the abeidentill property for inspection purposes.
Signature of Applicant/Agent: Date: � l J �3
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
ppr� VER-THF.COUNTER
y ❑ EXPRESS
(CJ ❑ STANDARD
❑ LARGE
a
❑ MNOR
MBPMrsc•App 2011.doc•revised 06/11/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20696 GREENLEAF DR DATE: 01/17/2013 REVIEWED BY: MELISSA
APN: 326 33 044 BP#: 'VALUATION: $3,288
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/Repair
PRIMARY SFD or Du lex PENTAMATION 1RPSS
USE: p PERMIT TYPE:
WORK INSTALL N PROPERTY LINE CLEANOUT
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 1 # $23
TOTALS: e , $23.00 `
, ° S` 1 �.. rIa F •. ar5'k Y)sHi . .
,.�.'?'�n'.x!.SNzt9iL��=�{I
:kfech..Plan Check - Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Me& Perndf Fee,: I Plumb.Permit Fee: IPPERHIIT I Elec.Permit Fee:
Other Afech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec.Insp.
:Vech../nsp. Fec.' I P/unib. hisjx Fee: Elec.Insp.Fee,
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc.). These ees are based on the preumin in ormadon available and are only an estimate. Contact the'Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $23.00
PME Permit Fee: $45.00
Consowction Tax:
Administrative Fee: 1ADM1N $42.00
Work Without Permit? O Yes O No $0.00
T 7771
Advanced Planning FeeS:
Travel Documentation Feer ITRA VDOC $45.00 A
Strong Motion Fee: IBSEISMCR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
55"4;, iits 11 ' HE sisrsol $0.00 �TU��,i FEE'S $156.50
�\ Revised: 10/01/2012
n \V