08050155 CITY 0 CUPERTINO 777,,�
BUILDING DIVISION PERNUT �"'C'0 NT"'RATT�Cffl)
PERMI't NO.
"�WTMOPPY DR ABLE SEPTIC 08050155
'NER'S NAME: PERMIT ISSUE DAM
PAVIC MARY A AND ZELJKO P 0 BOX 24819 05/20/2008
ONE: SANITARY NO, CONTROL NO.
(408) 377-9990
BUILDING PERMIT IWO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOWS DECLARATION
UM I lamby afflon that I am[caused under provisions of Chapter 9(conameakin, Job Description
z with Section 7000)ofliovision 3 offt Ramada arad Protestation Code.and my Ikama is REPAIR EXSTNG SEWER LINE
�,�w in full to=and efft q7
'13Z Uanumaks, Like L.Wr.
D M Con
__-/--/ V ARCHITECTSDECLA-M-flIO—N
0.1 1 understand MY plans"I x used as public records
D-U
I:�
W Licensed PoifiessionAl
OW14FR
_BUIWER DECLARATION
I bamby afrom that I am exempt from the Commators Uccnw Law for the
COO following Mason.sestion 7031.5,Busimess anul Professions Cola:Any city or=my
.9 which mean.tt permit..commum.1tcr.anion.,deamlish,or ropm,an,strusum
prior an its issuance.alm rectuiras the applicanal far such permit to file a signed soncennit a
that he is iiccnwd pummant to thm previsions of the coruscate,Liecesse Law(chapter 9 Sq.Ft. Floor Are Valuation
.�c (etmarencing with Sees.70DO)a(Division 3 of the But.and Prof.m.Cods)Mr $3239
e;R that he I.couniat thencilm.and the basis far the alleged..,it..Any ictlatfun of
Section 1031.5 by M applicant for a Permit subjeas,the aplicam,to a civil penalty a
on,a.M.five hundred dollars(SYM 34212 091 Ad)8;Number Occupancy Type
0 1."owner of the PrOMMY,or my creployem witin"gas"their=)a cooperasumn.
will de the ,it,and ussmae.is not mounted or.flinal far stake sec.70",Eaton.
and Prolimsm.Coake The Corauracaor�,I.Law does act pply to..mancer of Required Inspections
property who Wildrairaposams thereart.md wbodoostuchworklememifor through his
�mploy=.provi&dftt=bimp��m=mtin�nd�woffemdfwsal-if.
however.Me Wilding or uninoweracrat Is mid within am year ofcomplasion.the marks,
Mirka will have the bermiles of proving that he did act bodid or improve for purpose of
sale.).
0 Las owner of the property.am exclusively contracting wilin licensed contractors to
combect ft imeject(Sce.7W.Business and Prolcesims Cod.:)Tate Countesses U. RY
comm Law does not apply to an ownm�of propenty who Wild,or improves therearn.and z�AN TA
who contracts formsch projects;with.commmer(')licensed parmem,to Me ormarsens"
[Accause Lt-
0 1. amla mak"Ses. B&P C far the mat
Date
WORKER'S COMPENSATION DECLARATION
I humby affmat under penalty at perjury one of the following doclarstsions:
.it.,so provided far by Section 37M of Me Labor Code.far the perfam.of the
works for which ads permit is isesuml.
0 1 have and will eamoom Worize.Compensation Immumce.as ropured by Section
3710K).fiW La�Code,far the Md...of tiv,work for which dois .it is issued.
myworkeescomearmat.on Inummuss,canier and Policy number me
AMPDX,1Z,"#A0-4 Palley N.,MA�VE6 76
CERnFlCA1E OF MEMPTION MOM WOZUZ
COMPENISATION INSURANCE
(This means,need ran W compichall flake Mrask I,fortune hundred dollars($100)
or 1.)
I amif�y Met in dre performan=of the work for which this permit is isswul,I shall net
employ any peourn in any camancrat,ast an hecouse subject to ft Workcm�Compensation
LawntafCalitcum.Date,
AlMlicaust
NOTICE TO APPLICANT.If.nife,making this Certificate of Esemptles.you ho.]5
be.subject no ft Workers Contamination incoutions of us,Utters,Coth%you
z forthwith st-III with each ponvisms.or this isermit,latil be decround reocked.
z 2
CONSTRUCTION LENDING AGENCY
I hoolty,am.that them is a.mossuMther,leadirz.vaset far Lbe parform.of
the work for which this permit is Wood(Sec.3097.Civ,C.)
Leader's Name
U I orally than I have read WS application and ILAW that the,above inlormatfir.is
V�E correct I agree to empty with A]city and county onflnumosat and stam,laws mismi;in
0 Wilding cammuctim.,and heralsymthrome des city he ft
aluna-mentioned paperly for insixecoom pmivajaaaa�
I liabili (We)agree W save,indemnify and keep hantraIM the City 0fCMXsIinM!jM_'
V] tionjudirstomi,cML,mad exiterreas which may in my way mome alsout Mid City
Z in central.of the Zmatmg of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITII ALL NON-POINT Issued by:
SOURCE�ONS. — 9 � Date
Re-roofs
Signature of Aplic=Wr DA
US MATERIALS DISCLOSURE Type of Roof
Will the mplicam.,to,.Wilding occupse,some whandic baccardes,armus,
defined by the Cupertino Municipal Code,Chapter 9,11,som ft Nca,,an,Sgcty
sacbm,�532(.)?
cly. 1 /0 No All roofs shall be inspected prior to any roofing material being installed.
Will the aMlicarn or future Midi.,occospant.tumlipmen,or devicat whi,it If a roof is installed without first obtaining an inspection,I agree to remove
crail lounardimse sit emusnummus as darined by ft Buy Arm Air Quality Management all new materials for inspection.
DI=k,?
0yes IN.
I have mad the hanamossmaterials requirements underChapand.95ofthe Califor.
.I.FIcaILh&SaJ5,tYCas%San.U505.25533 MadviOd.I andeammaj dontirthe Wilding
data ran,trimmity have-tonsaft.that it is my numnstabilil,to andly Me,ranticartaf due
rarittimments h barractim Wom ttf.cczurkaako"�� Signature of Applicant Date
5M
Owner or Authorind agent Do& I All roof coverings to be Class';W'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. . . . . . . : 05/20/2008
RECEIPT # . . . . . . . . . : BS000004834 .
REFERENCE ID # . . . : 08050155
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 . . . . : ABLE UNDERGROUND
CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407
COMPANY . . . . . . . . . . : ABLE SEPTIC
ADDRESS . . . . . . . . . . : P 0 BOX 24819
CITY/STATE/ZIP . . . : SAN JOSE, CA 95154
• TELEPHONE . . . . . . . . : (408) 377-9990
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 3 , 239 . 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
1TRAVDOC 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 #7967
---------------
TOTAL RECEIPT 102 . 48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
•
P05 0 1-5
Suk-
CITY OF CUPERTINO
TREPIPE/SEWER/MAIN SERVICE
• CUPEI�TINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone#:
1v1G1�q�1 n Pqv/G ��30)392-2y6�
Contractor:
Able C,�C
Fax #:
Contact: Phone #:6/02) y71--7V27
C�Nz Avry
Fax#:
Contractor License #: 677'175'
Cupertino Business License #: 9--
Job
Job Description:
.J
Residential Commercial 0
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist& attacjj
it to the
application or if applicable, include in plan set & the sheet index.
SL—
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
CITY OF CUPERTINO
�� REPIPE/SEWER/MAIN SERVICE
CUPEkTINO 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
1RPWS
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
/ 1PPERMITFEE 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
CITY OF Fax(408)777-3333
OLUPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
.;x6.21 po r. J D 5 5
OWNER'S NAME: &—aQA,417 10411116 PHONE # - 2
GENERAL CONTRALTO �j FAX #
I am not using any subcontractors:
ignature 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
FROM :COPERTINOSRNITARYDISTRICT FAX NO. :4082535173 May. 22 2008 08: 16AM P1
• DISTRICT MANAGER-E] GINEER 'OQ SANtr�,,e/
.P BOARD OF DIRECTORS
MARK THOMAS 6 C0 PANY,INC. - '��� VVILL1AM A.BOSWORTH
RICHARD K.TANAKA JOHN M.OATTO
OISTRICTCOUNSEL YEA 2S OE CURTIS B.HARR15ON
SERVI'E
ATKINSON•FARASY .LLP. 'tB(ta qEO��Ov W ENDELLH.KERR,JR.
HAROLD S.TOPPEL CHRISTOPHER C.LEE
20533 STEVENS CREEK SOULEVARD,SUITE 104
CUPERTINO,CALIFORNIA 980142164
(408)2630071 PHONE - (408)2636178 FAX
www.ciipertinosanitorydisIrict.com
File: CuSD—MOP
Building Dept. -•Cupertino
City of Cupertino
Attn.: Building Department
10300 Torre Ave.
Cupertino, CA 95014-3202
I
Subject: Repair Existing Sewer Line
Name: Fei-Qiu Qi Residence
• Address:22621 Poppy Drive
APN: 342-12-091
Permit No. 08050155
■ Videotape v nd Property Line Cleanout inspected.
No addi oval condition,�rrqu'rements by the District,
Inspector: ony Soares:' .F„ ........
i
Date:...05 2-2008................... Sanitary Sewer Location:
cc: Property weer 10' Long
3' Deep
4' L/PL
SUPPLYING SANITARY SEWE GE SERVICES FOR:CITY OF CUPERTINO,PORTIONS OF THE CITIES OF SARATOGA,SUNNYVALE,LOS ALTOS AND
SURROUNDING UNINCORPORATED AREAS