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B-2016-1180C CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1180 22820 SAN JUAN RD CUPERTINO, CA 95014 (342 21 024) (GAGNE BROTHERS ENTERPRISES INC) NOVATO, CA 94949 OWNER'S NAME: HUTTON THOMAS J AND PAULA TRUSTEE DATE ISSUED: 01/13/2016 OWNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: r License Class Lic. # 5 (,73S—l O Contractor( GAG NE BROTHERS ENTERPRISES INC 1 Dates 1)13 6 X BLDG —ELECT X PLUMB - MECH X RESIDENTrar, COMMERCIAL 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. JOB DESCRIPTION: REPLACE (E) SEWER LINE & PROPERTY LINE CLEANOUT I hereby affirm under penalty of perjury one of the following two declarations: 1. 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 ,' F performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for'�� + m ' f' by Section 3700 of the Labor Code, for the performance of the work for which' Sq. Ft Floor Area: Valuation: $16900.00 this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above Number: Occupancy Type: information is correct. I agree to comply with all city and county 321 024 42 342 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, costs, and PERMIT EXPIRES IF WORK IS NOT STARTED expenses whit ay-accruslaga St said City in consequence of the Add!iti!S�DaIry, the and will WITHIN 180 DAYS OF PERMIT ISSUANCE OR grantinpef1fiis permit. applicant understands com -I with all non-oi rce regulations per the Cupertino Municipal 180 DAY INSPECTION. Code, Se 18. f / 445 /! l( Signature Date: OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (See.7044, Business & Professions Code) Signature of Applicant: 2. I, as owner of the property, am exclusively contracting with licensed Date: contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: t. 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the z. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. I will by Section 3700 of the Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the this permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous s. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which emit hazardous air contaminants defined ay Area uality Management District I shall not employ any person in any manner so as to become subject to the will maintain complian with the Cupertino icipal Code, Chapter 9.12 and Worker's Compensation laws of California. If, after making this certificate of the Health Safety Code, Sis 5 05, 25533, and 25534. exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall Owner oized age f au horf be deemed revoked. Data" �J j3 [/ APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant ARCHITECT'S DECLARATION understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records. Cupertino Municipal Code, Section 9.18. Licensed Professional Signature Date _._ _.. GENERAL PERIlif i APPLICATIONMEP 6 COMMUNITY DEVELOPidiEN T DEPART MEN T • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 9501'-3255MAI CUPERT[NG (408) 777-3228 • FAX (408) 777-3333 • build ino(a1cuDerinD.ora U— (3- 201 1 180 LU]; iNG nNEi caA2\ZCAI, 7ELECTRICAL 71;,HSCELL,0�t-OliS PROJbCT-DDRESS �1 L� I �?�i S- 1 V! r Z 0 [ 2 STREET?DDRES-c I CITY, ST.4TE,L -V V (1A. FAX CONTAgT Tkh!5 116. tiv�c�stiv� STRErT A DDRcS$.� Sn CITY,� TATE, Z3 �9 [ I FAX S� C (L "—C G• 9 ❑ OF'._R ❑ OWNEP-BUILD-Ek ❑ 07":N t AGc?\T C01\7 P SCTDR ❑ CO1\-P kCTOR AGM:T ❑ ?RC' 7 ❑ ENG='ERR ❑ DE-'rLOPER ❑ '7RkC- C LICENSEMuhS- ER 113 TI I BUS. LTC L STREi7-DRESS P`iO:'E kRCi�TECTEnGLN�Ei2NAA4E I LICENSEI\°U 3ER I BUS. LIC;: COIJ,PA_,vY NAIL- E-I� A TT. I FAX STREi1 ADDRESS I CITY, STATE, ZIP I PHONE USE OF ❑ S7 or DUPLEX ❑ l,!ULTI-Fpl,ffi Y PROI=CT 1N wII.DLA•1\'7i ❑ Yz-S ?P.07= -CT L*I ❑ ti=5 lS T E BLDG AN ❑ =s BU I2\1G: ❑ CO1'O,!::P'CIAT- URBL?; CE.ip. 4 ❑ NO FLOOD ZO13 ❑ ),0 EICIiLER$OIJB7 ❑ ?:•0 I DESCRIPTION OF PrORiC / 20-��Q_-E S&j1 e, ,) G © 4z4'r I . k c qq-,`l c A, TOTALS? .LU -.T!01\,: IM Mi By my signatu e below, I ce ifs to . ,e: I zn the prope_-y owner or auho izC nt b zct o r proo�, applicati0n and he inform- have provided is torr- t. I have read he Description of = and ver fj� i` : act e l to comply;; ith all applicable local ordl-antes and state lFws elarr to bui]di^F cons tion. I authorize representatives of CLD ---,Lino to enter `h ab e -idea ' edpropei y for inspection purposes. Sim— of.App'_ic_n /""-.-en : Date: _ h� SUPPLEMIENTAL DNFORvIATION REQULRED ' l"EPMITSC4-vP_2011.doc revised 06/21/11 CITY OF CUPERTINO FFT ESTIMATOR — BUILDING DIVISION ADDRESS: 22820 SAN JUAN RD TDATE: 01/13/2016 REVIEWED BY: MELISSA APN: 342 21 024 BP#: *VALUATION: 1$16,900 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Plumb. Plan Check PENTAMATION I PERMIT TYPE: I RPSS WORK REPLACE (E) SEWER LINE & PROPERY LINE CLEANOUT SCOPE APPLIANCE / EQUIP TYPE FEE ED QTY/FEE QTY UNITS BP FEES Sewer, Sanitary A I PRSEWER Plumb. Plan Check 1 # $25 Phin Cher -k TOTALS: $25.00 TOTE: 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 aaan't info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/131 FEE QTY/FEE MISC ITEMS Plan Check Hech. 1'hin SnppL F-1 Plumb. Plan Check 0.0 hrs $0.00 Phin Cher -k Supl-d' Plumb. Permit Fee: IPPERMITPer'w'I't $25.00 P-ee.- $48.00 Other Plumb Insp. 0.0 hrs $48-00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $2.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 SUBTOTALS-$169.20 1 $0.00 TOTAL FEE. $169.20 TOTE: 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 aaan't info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/131 FEE QTY/FEE MISC ITEMS Plan Check SnppL F-1 PME Plan Check: $0.00 Supl-d' PME Unit Fee: $25.00 PME Permit Fee: $48.00 Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $2.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 SUBTOTALS-$169.20 1 $0.00 TOTAL FEE. $169.20 Revised: 01/01/2016