08050093 CITY OF CUPERTINO y��a A-r
BUILDING DIVISION PERNIIT 11, r�; 11� C 'ORM
BUi 4 PERMIT NO.
�N ES�OPPY DR GREAT AMERICAN PLUMBING CO 08050093
ER'S NAME: Tmc PERMIT ISSUE DATE
PAVIC MARY A AND ZELJKO P 0 BOX 26942 05/12/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 279-1515
ARCHITECffENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MUCH
woo LICENSED CONTRACTOR'S DECLARATION Job Description
UW 1 hmcby affirm that I ren liaomd under yrnvisiom of Chopper 9(commencing p
wiles«da tIX1U)aroivmnn3ar�heBuan«.andPrare..;amenae,wmyliem�id SEWER LINE RPLCMNT USNG PIPE BRSTNG TECH.
n full forte and effect e O I bq
.nut
License CI Lle.g
n t-� Data u Conlram�' 13Lwt/- Wyds- -
gg ARCHRECTS DECLARATION
Wu I uMerdplansnd my plans shall be wed u aoN
public ra
g a i; Liromed Pmfcuional
SD5 OWNER-BUILDER DECLARATION
N I batch,afnn that 1 am escmpl from the cmuractes Lions Law for the
i.a o following mason.(Suction 7031.5,Bwiscu and Prokstsiom Cads:Any city or county
$9 which aropm.a parmit s covlruct.altar.hnpnoe.darmRsh,Or rtpm,any swnum
prior to its issuance.saw mquiras lM Applicant for such pormiuo file a signed moment
R< thatlsislicensedparwantstheprovisionsofdocComneuhli¢amiaw(Chapt«9 Sq.Ft. Floor Area Valuation
o (ammancingwithStation7000)ofDivision3ofineBuriom;andProfasinmCode)er $4200
- that he is eaempl Therefrom and the basis far the alleged eampdon.Any violation of
Smshm 7031.5 by any applicant f«a permit subjects the applicant to a civil pealty Of ane Number Occupancy
n« o
mm than fiw huadmd dollars(5500). 3 4 212 0 91 -V(54 NumP Y Type
❑1,asmw«s of the Property.or my emplayces with wages as their sale campemada,
will do roe won,and the s amumu mu mounted or enamd For sale(s«.M44.Business
and Pmficamom Cade:Ths Cmancse,License Law doss not apply b an mamer of Required Inspections
pmpmywW builds or improves memt and who docamch won hivsscif«through his
awn employes,provided that such impmo mints art not inuMed«mRed far sale It.
however,Ne Wilding or improwmmt is sold within ams year of ampledon.the owm-
Wilder will haw the tarda of proving that he did not build!«improve for purpose of
sale.).
El 1,u wrcr of the Sm.704.B es .and contracting with licensed anuant«s b
amtmm Lou,d pa.jm(sea t. .a,of and Py who
code:)The conmcbh u-whoa dam not apply b is owner of psapmty who Wilds or improves meson,andSANITARY
who contracts;f«dYellpmfeela with aanaYlaf(a)IlanYd pin30anlbrot GaaYCbh
I,kens tomo.
p l an eaempt ander se .B&Per«dda te�an
Dow
WORKER'S COMPENSATION DECLARATION
I hemby elf.under penalty of perjury,one of the following declanuam:
0 INwWwillmainWn•Ccdr=wofCav tbself-imamf«W« sCompca,
cation,an provided f«by section 3700 of the Labor Cade,f«the pmforom a of the
wort for which this psnnit is mucd.
❑1 haw and will maintain Workers Compenuuon Iowan¢,as nyuirtd by Semim
3700 ofthe Lmor Code,for the pnformams ofthe wwk for which this permit is issued. '
My Workers Com�QBmatin btsun«e tori«and Polity numbr,
an:
Carrier.131`ISD 3 55[� polity No.:TTT.LC1f I nS.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thuscdre reed rot ho campled iftho pmmh isfwonchundoaftat s(5100)
or less.)
I amity,thus in me perfamsnce of the wan f«which this permit is issued,l shall not
mtpl%any patron in say maaerso as to become subject to the Waren Compemation
Laws of Califomin.Dau
Malicatd
NOTICE TO APPLICANT:If.afar making this Cendiias of Esmption,you should
become subject In ds Workm'a Campcwation provisions of the Labor Code,you most
.J O forthwith amply with such previsions«this permit mal moke
he amoud sd.
'Z "" CONSTRUCTION LENDING AGENCY
(+� 1 bmbY off.that rocs u a ca don landing agency for the performamed
C> the wan f«which dos permit is bound(sea.3097,Civ.C.)
QLender's Name .
2 LendersAddmu
U O I certify,that I have sad this application and sus this lho show Infomatim u
Li.;` comm.1 agree s comply with all city and county amina«es and eau laws slating s .
O rV' building construction,and hemby audmaim spmomhadves of mu city to asr upon me
[17 -how-mendoncd property f«iwpecuon purposes.
f~ 4 IWc)agme to caw,indemnify and keep hornless ds City of Catania.against
vyh liabilities.judgmcnu,costs and umadam which may in any way amuc agaiml said City
U Z m amequetse of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
S Issued by: Date
RF¢EGU .L
S ONS�j�� Re-roofs
s'Pa.a[AIianaVativame, Das
HAZARDOUS AT9 DISCLOSURE Type of Roof
Will the applicant or future Wilding mupat store or handle haumous maurial
defined by de Copeman Municipal Cads.Chaptar 9.11 and the Hnlm and Safety
.semim2ss32(a)7
❑yes AWB All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or futum Wilding occupant usa eyuipmat or devices which If a roof is installed without first obtaining an inspection,I agree to remove
��
fo
h rd— um
air cainmu u de0ad by me Bay Am.Air Quality Mangemem all new materials for inspection.
❑Yes
I haw mad de hassrdou/s7'mauriab mlfuimmcnu mula, lupum 6.95 oftho Calif«-
ni-Hcahh&Safety Coda.Sahom25505.15533 and 25514.1 undcuund that ifthn Wilding
d«a at mmudy haw a IenNl That it le my oupouch,bty b mury de amomm,or me
mry mon aahoms orb a-naarac«ae..ofOccupancy. Signature of Applicant Date
�— S•/ -O
Owner ar a norvcd-gc Data All roof coverings to be Class'.aa or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 34212091 . 00
DATE ISSUED. . . . . . . : 05/12/2008
RECEIPT # . . . . . . . . . : BS000004731
REFERENCE ID # . . . : 08050093
SITE ADDRESS . . . . . : 22621 POPPY DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PAVIC MARY A AND ZELJKO
ADDRESS . . . . . . . . . . : 22621 POPPY DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0802
RECEIVED FROM . . . . : GREAT AMERICAN PLMB
CONTRACTOR . . . . . . . : CORPORATION LIC # 18061
COMPANY . . . . . . . . . . : GREAT AMERICAN PLUMBING CO INC
ADDRESS . . . . . . . . . . : P 0 BOX 26942
CITY/STATE/ZIP . . . : SAN JOSE, CA 95159
• TELEPHONE . . . . . . . . : (408) 279-1515
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 4, 200'. 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRSEWER UNITS 1 . 00 20 . 40 0 . 00 20 .40 0 . 00
ITRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 102 . 48 0 . 00 102 .48 0 . 00
METHOD OF PAYMENT AMOUNT '- REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 102 .48 #105781
---------------
TOTAL RECEIPT 102 . 48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
507 FINAL PLUMBING
-� CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEIkTINO PERMIT APPLICATION FORM
APN # 2 yA a o 9 ' o Date: r
Building Address:
r or CGC t Po P\1
Owner's Name: ho e#:
�kcxT\( cknn ��v« y157-
Contractor: Phone#:
-s�/S mower and 1�rain
Fax#:
Contact: Phone#: 4(og. 7aQ(�
Fax #:
Contractor License#: Set b(js foot
Cupertino Business License#: o
Job Description:
�v,}e.✓ t+��. 'V'c_�crCeiN1•e✓1;�' t.rsrN� ��r�-. ��nr:S�l1��i '�'ecl�
Residential Commercial Q
Valuation: , LOo
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set& the sheet index.
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1 BPREPIPE Commercial re-pipe per fixture P 1CPRP
1 PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
1BSEISMICR Seismic Residential P
IPRSEWER Residential building P 1RPSS
sewer/sanitary sewer
-� CITY OF CUPERTINO
CLY�' REPIPE/SEWER/MAIN SERVICE
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
IRPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit Fee Issuance P •
/ 1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel &Documentation Fee B
1BUSLIC Business License B
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
!01
IUPEkTINO Fax(408) 777-3333
Building De artment
JOB ADDRESS: PERMIT#
b'dc-iI f°PN PbS00`t3
OWNER'S NAME: cr Gh✓7 palkL PHONE #y.' • p2S .996cl
GENERAL CONTRACTOR /S inevLr a%r) FAX #
I am not using any subcontractors: =s 5. �d' 06
Si ature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
. Tile
Owner/Contractor Signature Date