13090102 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20667 CLEO AVE CO QCT(- WI-Hr+Efib/4_66F PERMIT NO: 13090102
CO
OWNER'S NAME: ATTIX CECELIA A TRUSTEE DATE ISSUED:09/13/2013
OWNER'S PHONE: 4082530567 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALE]
License Class Lic.# -76 y67� REPLACE(E)SEWER LINE&INSTALL(N)PROPERTY
c c LINE
ContractorDate 3 3 CLEANOUT
I if
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions NITARY
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3000
�- I have and will maintain Worker's Compensation Insurance,as provided for by
y Section 3700 of the Labor Code,for the performance of the work for which this
APN Number:36231021.00 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 WITIUv 180 D ERMIT 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 CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgmen ,
costs,and expenses which may accrue against said City in consequence of
granting of this permit. Additionally,the applicant understands and will c Issued by: Date: 111
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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 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,Sections 25505,25533,and 255
Section 3700 of the Labor Code,for the performance of the work for which this !3
Date:
permit is issued. Owner or authorized agent:
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
v
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION n o
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (J�
CUPER
1-31
(408)777-3228•FAX(408)777-3333•building(a)cupertino.org f{„
misc
r PLUMBING /❑MECHANICAL ❑ELECTRICAL []MISCELLANEOUS
PROJECT ADDRESS 2,o66
,O66 Cleo
77:36
2- ^ � / D 2OWNERNAME / ece t`\� Aii!)�(' PHONE 0 ,�,056 MAIL `
STREET ADDRESS !`� 2 t t „ /� CITY,STATE,ZIP / v (D � o FAX
CONTACT NAME �! / C/ PHONE6,6`�2_� 27 E-MAIL
STREET ADDRESS C ` CITY,STATE,ZIP ,(� FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 0 CONTRACTOR ❑CONTRACTOR AGENT 11 ARCHITECT 11 ENGINEER 11 DEVELOPER 11 TENANT
\/`/�
CONTRACTOR NAME \,A_� 66n ; LICENSE NUMBER X�J`f 076 LICENSE TYPE n BUS.LIC#
COMPANY NAME C E-MAIL 1� D FAX
STREET ADDRESS 53 CITY,STATE,ZIP C „a PHONE
�j - lu r
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES 7RO7CT IN ❑YES IS THE BLDG AN ❑YES
BUILDING, ❑COMMERCIAL - URBAN INTERFACE AREA ❑ NO LOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
AW_ oqArV pl <.P
ck s cd e aj I ( ar `�
I /A be y
TOTAL VALUATION: .
By my signature below,I certify to each of the following: I am the property owner or au orized agent to act on perty I have re
application and the information 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 bTz::N�
tatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: A13
SUPPLEMENTAL INFORMATIONREQUIRED
}
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20667 OLEO AVE DATE: 09/1312013 REVIEWED BY: MELISSA
APN: 362 31 021 BP#: "'VALUATION: 1$3,000
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPSS
USE: I I PERMIT TYPE:
WORK REPLACE E SEWER LINE & INSTALL N PROPERTY LINE CLEANOUT
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $24
TOTALS: $24 00
n„..
:Leech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan(:;heck
llec;h.Permit Fee. Plumb.Permit Fee: IPPERMIT Flec.Permit Fee:
Other:leech.Imp. Li Other Plumb Insp. �hrs $47.00 Other Elec.Insp. Li
dtech. Insp.Fee. Plumb. lisp.Fee: Elec.Insp. Fe
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the prelinmdina information available and are on an estimate Contact the De t or addn7 info,
FEE ITEMS(Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC:Fee
PME Plan Check: $0.00
f errnit Fee:
Supj)l. Insp Fee
PME Unit Fee: $24.00
PME Permit Fee: $47.00
(7onsmuction Tar:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes 12) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$163.50 $0.00iE
$163.50
Revised: 08/01/2013