15060075CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10200 MILLER AVE
CONTRACTOR: BURR PLUMBING &
PERMIT NO: 15060075
PUMPING INC
OWNER'S NAME: FONTAINBLEU LLC
1645 ALMADEN RD
DATE ISSUED: 06/11/2015
O�WNE PHONE: 4084469898
SAN JOSE, CA 95125
PHONE NO: (408)287-2877
LICENSEO CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
License Class Lic. #i'�:. '.+ ..
INSTALLATION OF BACKFLOW DEVICE ON WATER
MAIN
� �C �-" :_, I
(WILKINS 375 OR 475).
Contractor �� 3 .. �+ ate ��-
I hereby affirm that I am licensed under 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 havSand will maintain a certificate of consent to self -insure for Worker's
C pens ' n, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $9850
e Hance of the work for which this permit is issued.
ave 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
APN Number: 37503005 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 D ROo
M LAST CALLED INSPECT ON.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
(((� '�
Issued by: Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cu Municipal Code, Section
RE -ROOFS:
9 18.m.: __ .
. 7. - g•...-.
Signature er'"Date
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
1, 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (See.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 Qual' Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino ' al Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505 , and 2 34.
Section 3700 of the Labor Code, for the erformance of the work for which this
_ •.._r.
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
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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: 10200 Miller Ave DATE: 06/08/2015 REVIEWED BY: Sean
APN: BP#: *VALUATION: $9,850
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Buildina is PENTAMATION
USE: Multi -Family Dwelling >3 Stories 0 Yes E) No PERMIT TYPE:
WORK I Installation of new backflow device wilkins 375 or 475).
SCOPE
IRPBF
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check0.0 hrs $0.00
QTY
UNITS
BP FEES
Vacuum Backflow
1PATMOBF
; irla•,• ! r., . h,S r •,.
1
#
$72
.SuPpl fns/) VC(?
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
_T7 C nusn ru rind 7
Administrative Fee: IADAMT
$45.00
Work Without Permit? 0 Yes (E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$72.00
Strong Motion Fee: IBSEISAftCR
1VUj&. it Ins estimate does not include fees due to other Departments (ie. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc 1. These fees are hated an the nroliminnnr infarmalian availahlp and ara onk an o dimalo Canfort flip none for addn'l info
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1113)
FEE
Plumb. Plan Check0.0 hrs $0.00
MISC ITEMS
Pion C'17eL•l,. FCC.
Plumb. Permit Fee: IPPERAIIT
S<rl�f,l. PC ke.e
Other Plumb Insp. 0.0 hrs $48.00
; irla•,• ! r., . h,S r •,.
1'!1,11,/,. Mv. 1 E�<;
!7L•
1VUj&. it Ins estimate does not include fees due to other Departments (ie. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc 1. These fees are hated an the nroliminnnr infarmalian availahlp and ara onk an o dimalo Canfort flip none for addn'l info
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1113)
FEE
QTY/FEE
MISC ITEMS
Pion C'17eL•l,. FCC.
S<rl�f,l. PC ke.e
PME Plan Check:
$0.00
.SuPpl fns/) VC(?
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
_T7 C nusn ru rind 7
Administrative Fee: IADAMT
$45.00
Work Without Permit? 0 Yes (E) No
$0.00
. i<lvr,7��rt 1'l�urJrirr; f•en.�•:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISAftCR
$1.28
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:,
$215.28
$0.00 TOTAL FEE -.-.I
$215.28
Revised: 05/07/2015