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15080182CITY OF CUPERTINO BUILDING PERMIT 13UILDING ADDRESS: 10520 S DE ANZA BLVD CONTRACTOR: PLUMBING TECH INC PERMIT NO: 15080182 OWNER'S NAME: HARMAN -MANAGERS INVESTMENT INC 1040 HARANA DR DATE ISSUED: 08/25/2015 OWNER'S PHONE: 4082535057 SAN JOSE, CA 95122 PHONE NO: (408) 836-2492 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL S KENTUCKY FRIED CHICKEN - REPLACE (E) PROPERTY License Class Lie. # 3 7 LINE Convector Vq Date S CLEANOUT 1rtk-k Revision #1 -Install 60' of trenchless building sewer line from I hereby affirm that I am licensed under the provisions of Chapter 9 building cleanout to (N) property line cleanout (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 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: $2400 I 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 UPN Number: 36939017.00 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 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 � 11 �` �nI� 5UUJM4, Issued by: Date: L tom/ V - granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per Cupertino Municipal Code, Section RE -ROOFS: 9.18. U� Signature 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 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. 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(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 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Munici a ode, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safe Sections 2550 , 533, a 2 34. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized n . 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 ��,�,CITY OF CUPERTINO W , FEE ESTIMATOR — BUILDING DIVISION 61' ADDRESS: 10520 S DE ANZA DATE: 09/02/2015 REVIEWED BY: PAUL UNITS APN: 369 39 017 BP#: 15080182 *VALUATION: Iso *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building # PENTAMATION PERMIT TYPE: 1CPS WORK Revision #1 -Install 60' of trenchless buildin sewer line from buildin cleanout to N roe line SCOPE cleanout APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES Flee Permit T".. -L-- Sewer, Sanitary 1 PCSEWER Of Elec. Insp. E3 1 # $25 Permit Fee: Suppl, Inst, F'ee PME Unit Fee: $25.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: IADMIN $45.00 Work Without Permit? Yes (j) No $0.00 TOTALS: Travel Documentation Fee: ITRA vDOC $25.00 Stronjz Motion Fee: IBSEISMICO NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the oreliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E ..' 7/1/13) Gtech. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 !aec. Plan Check r�fech. Plumb. Permit Fee: IPPERMIT Flee Permit T".. -L-- Orher Mech. Insp. Other Plumb Insp. 0.0 hrs $48.00 Of Elec. Insp. E3 sVIech. Insp. he e: PME Plan Check: Flee. Insp. Fee NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the oreliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E ..' 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Pee: Su pl. P(' T'ee PME Plan Check: $0.00 Permit Fee: Suppl, Inst, F'ee PME Unit Fee: $25.00 PME Permit Fee: $48.00 Construction Tax: Administrative Fee: IADMIN $45.00 Work Without Permit? Yes (j) No $0.00 Advanced Phinni.ng Fees. Travel Documentation Fee: ITRA vDOC $48.00 Stronjz Motion Fee: IBSEISMICO $0.00 ! Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $166.00 $0.00 TOTAL FEE: 1 $166.00 Revised: 07/02/2015 9r CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10520 S DE ANZA BLVD CONTRACTOR: PLUMBING TECH INC PERMIT NO: 15080182 OWNER'S NAME: HARMAN -MANAGERS INVESTMENT INC 1040 HARANA DR DATE ISSUED: 08/25/2015 OWNER'S PHONE: 4082535057 SAN JOSE, CA 95122 PHONE NO: (408) 836-2492 Pf LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL KENTUCKY FRIED CHICKEN - REPLACE (E) PROPERTY License Class Lic. # 57-4a LINE Contractors Date CLEANOUT 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. SANITARY 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 Sq. Ft Floor Area: Valuation: $2100 performance of the work for which this permit is issued. 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 APN Number: 36939017.00 Occ upa nc� "1.Npc 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 WIT�IIN 180 DAY T 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 M LA 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 comp) "Issued b - _ _ Date: e / with all non -point urce regulations per the Cupertino Municipal Code, Section 9.18. 4tll RE -ROOFS: Signature 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: 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 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 (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 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(a) should I store or handle hazardous 1 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 1 performance of the work for which this permit is issued. will maintain compliance with the upertino Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sectio 25505, 2553 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. 1 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 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION WWI 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 ddmbvL (408) 777-3228 - FAX (408) 777-3333 • build! noCdDCUDertino.org 1S-690 -2— MECHANICAL PROJECT ADDRESS S' \�z 4K APN n 3 9 — V O Ek NAME s �I , PHONE I — - 9 k c 'a.rN'►� I` - ctta n goma $Tp CONTACT NAM- PHONE 61 q �ZIAIL FAXS E -?✓AIT STREET ADDRESS CITY, STATE, ZIP kanTlas-e CA r'.AX ❑ O14TLR ❑ O1l'NFR-BUILDER ❑ OFiR.'ERAGENT ;eC0N7FACT0R ❑ CONrRACTOR AGENT ❑ ARC?SECT ❑ ENGINrc.R ❑ D1,LOPER ❑ TENANT CONTRACTOR ' 'mLIC Y' ' E NUA ER LICEN -- E BUS. LIC n M, NAME NAIL EMAIL FAX STREET ADD S CITY, STATE ZIP 05 le- -OoC1'O ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COMPANY NAME E-MAIL, FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD .,DUPLEX ❑ MULTI-FAMMY - BU=NIG: ❑ COND II=CIAL I PROJECT P.' N'IIALAND ❑ ),ZS PROMCT IN URBAN LN7ERFACE AREA ❑ NO FLOOD ZONE ❑ YES ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF W ORK r��� ✓ / // � ��/L� C / ' - r/ TOTAL VALUATION: �/ ItYC/ Qx By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct ave read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating uilding cons . I authorize representatives of Cupertino to enter the above -idea ' ed pro erty for inspection purposes. Signature of A.pplicant/Agen Date: 2 SUPPLEMENTAL II\TFORMATION REQUIRED T "ITiCE USE ONLY 0�'EJ: "IHE-COC�TEI2 >J ExPRESS. � Lr;SD'.RD MEPAIisc4Pp_2011.doc revised 06121/11 CITY OF CUPERTINO I�JI FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 10520 S DE ANZA BLVD DATE: 08/25/2015 REVIEWED BY: MELISSA UNITS APN: 369 39 017 BP#: 'VALUATION: 1$2,400 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: # PENTAMATION 1 RPSS PERMIT TYPE: WORK KENTUCKY FRIED CHICKEN - REPLACE E PROPERTY LINE CLEANOUT SCOPE ' "iq, d. Irish T ire APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES F,Icc. P<<rwit Fee: Sewer, Sanitary 1 PRSEWER = i;lrer l_;7�:c. hl'sp.ET 1 # $25 Permit [,'ee: ' "iq, d. Irish T ire PME Unit Fee: $25.00 PME Permit Fee: $48.00 Construction Tt/X. Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 TOTALS: i Travel Documentation Fee: ITRA VDOC $25.00 Strong Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-033 L(t: 7%1%73) Mech. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 l:lee. Plan Check Alec/t. Permit Fee: Plumb. Permit Fee: IPPERMIT F,Icc. P<<rwit Fee: Other .Uec•h. Insp. Other Plumb Insp. 0.0 hrs $48.00 = i;lrer l_;7�:c. hl'sp.ET Wch, Insp. he PME Plan Check: 7cc. Insp. he(,: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-033 L(t: 7%1%73) FEE QTY/FEE MISC ITEMS Plan (hc "k Pee: Supp!. PC , Fee PME Plan Check: $0.00 Permit [,'ee: ' "iq, d. Irish T ire PME Unit Fee: $25.00 PME Permit Fee: $48.00 Construction Tt/X. Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 -1dvunced Planning Fees. i Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item 1 Bldp_ Stds Commission Fee: IBCBSC $1.001 SUBTOTALS: $167.50 $0.00 TOTAL FEE: 1 $167.50 Revised: 07/02/2015