14070081 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10145 CARMEN RD CONTRACTOR:ABLE SEPTIC PERMIT NO: 14070081
OWNER'S NAME: BARRON CLAYTON W AND DOLORES J P O BOX 24819 DATE ISSUED:07/18/2014
OWNER'S PHONE: 4082574730 SAN JOSE,CA 95154 PHONE NO:(408)377-9990
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
NEW CONNECTION TO CITY SEWER.INSTALL(N)
License Class C.—Lt2 Lic.# c�,�� LATERAL
&2 CLEANOUTS(FOUNDATION&PROPERTY LINE)
Contractor Date
I hereby affirm that I am licensed t rder the provisions of Chapter 9 l '"
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
Ihereby affirm under penalty of perjury one of the following two declarations: AN
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:$6900
I 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:35701095 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 AS LLED 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 bj
granting of this permit. Additionally,the applicant understands and will co e'
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18
1 RE-ROOFS:
Signature Date j —1 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 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 25534. �}
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: - 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
CONSTRUCTION PERMIT APPLICATION
119 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �O
CUPERTINO (408)777-3228•FAX(408)777-3333•building(a)_cugertino.org o
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION In ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 10` 1' M(M_ yt ��..., APN# �].. O 1 O
OWNER NAME CI 1 ArM P PHONE Aurl 4-1so EMAIL ` n '' U�
STREETADDRESS 1 y� CITY,STATE IP watty, or(tn /� FAX CONTACT NAME a Ton-C S j PHONE L.1/„& ^1 q q &MAIL
STREET ADDRESS 1,`^,\ (444 A)r, CITY,S TE '` I 01V`u FAX " I V V
❑OWNER ❑ OWNERv --BUUBAER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME * 0h C' 16n.L LICENSE NUMBER. ,, 4-115
-1 15 LICENSE TYPE LAI_ BUS.LIC# n ,\
COMPANY NAME H EMAIL FAX G u
CAJ1-e ,(4j, l 00
STREET ADDRESS I 1\�y� n 3 / CITY,STATE,ZIP !r �� C j\ q�yo PHONE /�,` {�, 3l j.q a a
ARCHITECT/ENGINE\ERRNAMEv 1(/\/ `Jr 7LICENSENUMBER Y1 BUS.LIC[•#�v 6
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
V-
EXISTING USE PROPOSED USE CONSTR TYPE #S ORIES
USE TYPE OCC. SQ.FT. VALUATION($)
MSTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODELAREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: LJDETACH
❑ATTACH
#DWELLINGUNITS: IS A SECOND UNrr OYES SECONDSTORY OYES
BEING ADDED? ❑NO ADDITION? ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES _ - VCALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO l /, )
By my signature below,I certify to each of the following: I am the property owner or autho a—genttd'act on the property owner's behalf. I have read this
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 to4Zuildpgconstruction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: :11 Date: l
SUPPLEMENTAL 1ORMATION
REQUIRED PLAN CHECK TYPE ROUTnvc S LP
New SFD or Multifamily dwes: Apply for demolition permit for L 1�ER-THErCOUNTER ElBuILO NG PLAN REv>Ew
existing building(s). Demolition permit is required prior to issuance of building /
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ SrANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. 1 LARGE ❑ t,•IRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. MAJOR El SANITARY SEWER DISTRICT
❑ ENVHtONMENTALHEALTH
BldgApp 2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10145 CARMEN RD DATE: 07/18/2014 REVIEWED BY: MELISSA
APN: 357 01 095 BP#: *VALUATION: 1$6,900
rPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPS
WORK NEW CONNECTION TO CITY SEWER. INSTALL N LATERAL& 2 CLEANOUTS FOUNDATION &
SCOPE PROPERTY LINE)
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1 PRSEWER 1 # $25
TOTALS: $25.00
fc�"'1. 1,11 ir", Plumb.Plan Check0.0 hrs $0.00 LOC. !"I';,
.-./, Permit Fee: Plumb.Permit Fee: 1PPERMIT
L
lkci�. fTw,wr Other Plumb Insp. 0.0 hrs $48.00 Ov.)" `I rc( . s"""
i Pha"Ib. hap, Fee: Ia s,
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the relimina information available and are onlyan estimate. Contact the Det or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/132 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $25.00
PME Permit Fee: $48.00
T7
Administrative Fee: 1ADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
?(t�, .rotc{qtr';0rcxrt7fr�7
Travel Documentation Fee: ITRAVDOC $48.00 A
Strom Motion Fee: 1BSEISMICR $0.90 Select an Administrative Item
Bldg*Stds Commission.Fee: 1BCBSC $1.00
V '� $167.90 $0.00 TOTAL FEE: $167.90
Revised: 07/10/2014