B-2017-0567CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0567
10912 LEAVESLEY PL CUPERTINO, CA 95014-4789 (356 15 030) MARITS PLUMBING
OWNER'S NAME: GALET EDWARD JAND KAREN L TRUSTEE
OWNER'S PHONE: 408-996-0762
LICENSED CONTRACTOR'S DECLAR TION
License Class C-36 Lic. #958020
Contractor MARTI'S PLUMBING SERVICE Date 02/28/2019
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:
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
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
i� Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct. 1 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, costs, and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant underst ds and will comply with all non -point
source regulations per the�upeKino Municipal Code, Section 9.18.
Signatur.g"� //1✓1 / Date 04-12-2017
SERVICE
CUPERTINO, CA 95014
ISSUED: 04/12/2017
PHONE NO: (408) 375-3190
BUILDING PERMIT INFO:
BLDG —ELECT X PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
REPLACE SEWER LINE AT STREET
Sq. Ft Floor Area: I Valuation: $9218.14
"N Number: Occupancy Type:
35615 030
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: Kim Dunbar
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE. -ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for inspection.
sale (Sec.7044, Business & Professions Code)
z. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project (Scc.7044, Business & Professions Code). Date: 04-12-2017
I hereby affirm under penalty of perjury one of the following three 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
performance of the work for which this permit is issued.
2. 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
permit is issued.
s. 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 become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICANT CERTIFICATION
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, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature Date 04-12-2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25 33 d 25534. .
Owner or authorized agent:
Date: 04-12-2017
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
IiPER Ii�10 I (408) 777-3228 • FAX (408) 777-3333 • buildina(a)cu ertino.ar
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USE OF P.SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ -YEs PROJECT IN
URBAN` INTERFACE AREA ❑ NO FLOOD ZONE
❑ YES
❑ NO
IS THE BLDG AN ❑ 1'ES
FICKLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:
By my signature belod,41 certify to each of the following: I am the property owner or authorized agent t6 act o e p operty 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 to building ns tion. i thorize.representatives of Cupertino to enter the above -i entified property for inspection purposes.
Signature of Applicant/Agent: Date: /
SUPPLEMENTAL IN RMATION REQUIRED
oFFicE usE ons ..,
-
-'❑ OVER=THE-COIJnTER ---
:❑ EXPRESS
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❑ L4RGE
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MEPA7iscApp_M1.doc revised 06121/11
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CUPERTINO SANITARY DISTRICT
20863 Stevens Creek Blvd #100, Cupertino, CA 95014
Tel (408) 253-7071 • Fax (408) 253-5173 S�sJBR[fSHE0�9`'� G1Jp€r%TIlIQ
SANITARY DISTRICT PERMIT LETTER
Cupertino Sanitary District has adopted Resolution No. 9263.
Building Permit Request
(Over -the -Counter)
[Single Family Project ❑ Multi -Family Project ❑ Commercial Project
Project Address: ( b
Permit Number: (`7
Scope of Work:
V e u
Owner/Applicant Name: "— Vt [Kc_ Phone:
Date:
Prepared By:
City Authorized Representative
1, as property owner or authorized agent, acknowledge that all Cope
,"o Sanitary District requirements
will be met and all required fees will be paid e a roval�f`fi al inspec ion for proposed project.
Date: - �- Signature: -�
Own Authorized Agent
CUPERTINO SANITARY DISTRICT OFFICE USE ONLY
❑ Pre -inspection Required
Date Scheduled:
Final Inspection Required
Date: k_41—n— Conditional Approval By: Lv
Authorized Wresentative
Cupertino Sanitary District
District will notify owner of the required fee within 5 days after Pre -Inspection has been completed and cc
City of Cupertino.
[g Inspection Fee Paid Date Paid: 2—
Connection Permit Fees:
❑ $350/unit - Single Family Residential connecting to existing lateral (CCN & inspection
included)
❑ $650/unit - Single Family Residential connecting with new lateral (CCN & inspection
included)
$100/unit up to 4 units & $65 above 5 - Housing (Multiple, hotel, condo, living units, etc.)
$500/connection - Commercial & Retail (Permit only. CCN and inspection not included)
❑ $200/each - Disconnect Permit
Inspections:
$250/unit - Single Family Residential already connected, but new cleanout required
(CCN & inspection included)
❑ $150/unit - Single Residential already connected w cleanout (CCN & inspection
included)
Date: Final Approval By: KZA:AL
'-Authorized Re resentative
\ Cupertino Sanitary District