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111100061. 1 CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 22605 SALEM AVE I CONTRACTOR: ALLSTAR PLUMBING I PERMIT NO: 11110006 OWNER'S NAME: ALTMAIER RICHARD C AND PAULETT 1326 PHELAN AVE I DATE ISSUED: 11/012011 OWNER'S PHONE: 4082428999 1 SAN JOSE, CA 95122 I PHONE NO: (408)230-5569 LICENSED CONTRACTOR'S DECLARATION License Class Lic. q ContractorDate I hereby affirm thaAll 't I am licensed under the provisi ss o)06 (Ch/spter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: 1 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 whichthis permit is issued. 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. 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, 1 OWNER -BUILDER DECLARATION 10by affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 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. 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. 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 Cal ifomia. 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, Sj& and expenses which may accrue against said City in consequence of the ng of this permit. Additionally, the applicant understands and will comply all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: REPAIR BACKFLOW PREVENTOR & INSTALL NEW CLEANOUT Sq. Ft Floor Area: I Valuation: $5000 AIN Number: 34212062.00 _ ,s F+^y.rokupapfy Type: 1 +I$ I� WORK IS NOT STARTED n TH 80 AYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by Date: RF. -ROOFS: All roofs shall be inspected prior to any roofing material bang installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applimn ate: i ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should 1 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, 25533, and 25534. Owner or author[ rtt gent: Date: CONSTRUCTION LENDING AGENCY 1 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed • 1 CEATING GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinGCD cuoertinD,orD I I I I 000lp Ek 5i1r ING ❑MECHANICAL ❑ELECTRICAL_.___ []MISCELLANEOUS MEP M ISC FROM= ADDRESS 3 APN a' 3` 3' I -[_ f Go 7— OWNER NAME kA49� PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE - E MAD. STREETAODRESS CITY, STATE, Zr? FAX ❑ OWNEit ❑ OWNER-aULLDER ❑ OWNERAGENT ❑ CONIRALTOR ❑CONTRACTORAGENT ❑ ARCHRFLT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER V TYPE BUS. LIC e COMPANY NAME E-MAIL FAX STREET ADDRESSU CIN. STA PHONE O zaci ARCHMEC IENOINEERNAME LICENSE NUMBER BUS. LIC M COMPANYNAME' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE SE OF ❑SFO m DUPLEX ❑ MULTI -FA y BUDDING: ❑ OOmNmc AL PROIECrINWIDLAND ❑ YES []ARAN INTERFACE AREA E NO PROTECT LN ❑ YES FLOOD ZONE ❑ NO ISTHE-IDGAN ❑ YES EICHIFA HOME? ❑ NO DESCROMON OF WORK - TOTAL VALUATION: RECEIVED BY: By my signature below, I certify to each of the following: I am the property owner cr authorized agent to act on the property owners behalf. I have read this application and the information I have provided is correct j have mad the Description of Wark and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relisting to building con tion. I authorize representatives of Cupertino to enter the above -identified property for inspect= poroses. Signature of Applicant/AgenC' Daze. SUPPLEMENTAL INFORMATION . REQUIRED OFFICE USE ONLY <0-Tax-COUNTLR c Y ❑ EXPRESS U Z ❑ STANDARD U ❑ LARGE a, ❑ MAJOR AffPMIIcApp 2011.doc revised 06/21/11 0 • 6 ITEMS OF 6 LJ • CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34212062.00 DATE ISSUED.......: 11/01/2011 RECEIPT #.........: BS000015209 REFERENCE ID # ...: 11110006 SITE ADDRESS .....: 22605 SALEM AVE SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: ALTMAIER RICHARD C AND PAULETT ADDRESS ..........: 22605 SALEM AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5648 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 195.50 --------------- 195.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION ------------------------------------ 202 -------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL RECEIVED FROM ....: FAROUQ DAOUD CONTRACTOR .......: DUARTE TADEV LIC # 22189 COMPANY ..........: ALLSTAR PLUMBING ADDRESS ..........: 326 PHELAN AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95122 TELEPHONE ........: (408) 230-5569 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- ---------- -ADMIN ----------------------- HOURS 1.00 -------------------- 41.00 '0.00 41.00 0.00 1BCBSC VALUATION 5,000.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 5,000.00 0.50 0.00 0.50 0.00 1PATMOBF UNITS 1.00 65.00 0.00 65.00 0.00 1PPERMITFE FLAT RATE 1.00 44.00 0.00 44:00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 TOTAL PERMIT ---------- ---------- 195.50 0.00 ---------- 195.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 195.50 --------------- 195.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION ------------------------------------ 202 -------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL •im Ll • ,��,��,, CITY OF CUPERTINO I�V/il FEE ESTIMATOR -BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 2265 salem ave. DATE: 1110112011 REVIEWED BY: bobs. BP FEES APN: BP#: I 'VALUATION: $5,000 "PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD Or DU IBX USE: p $ea!srButtd PENTAMATION 1RPSS PERMIT TYPE: WORK re air backflow preventor and install new C/O. SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Plumb. Permit Fee: IPPERMIT f'ka;. Ptnmti Fe,c Oihee,lfech. hnp, Other Plumb Insp. 0.0 his $44.00 011ier t7ec. Imp. Much, Insp. Poo; Plumb fay. Fee: $ea!srButtd Permit Tee: Suppl. GaspTi.e Vacuum Backflow 1PATMOBF 1 # $65 PME Permit Fee: $44.00 Consiructiun Tax- arAdministrative AdministrativeFee: 1ADMIN $41.00 Work Without Permit? Yes (F) No $0.00 Advanced Planning F'eev: TOTALS: F Travel Documentation Fee: ITRA VDOC $87.00 Strone Motion Fee: IRSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, hlre, Sanitarysewer District, Smoot Dletrart eM 1 Thom fans are hosed on /ha Miminam infarmailan available and are only an estimate. Contact the Deal for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff 71111 1) .wee.h. Plan Check Plumb. Plan Check 0.0 1 his $0.00 Elec. Plan Check Mesh. Perrnil Fcc: Plumb. Permit Fee: IPPERMIT f'ka;. Ptnmti Fe,c Oihee,lfech. hnp, Other Plumb Insp. 0.0 his $44.00 011ier t7ec. Imp. Much, Insp. Poo; Plumb fay. Fee: Ek.(. hisp. Fee NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, hlre, Sanitarysewer District, Smoot Dletrart eM 1 Thom fans are hosed on /ha Miminam infarmailan available and are only an estimate. Contact the Deal for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff 71111 1) FEE QTY/FEE I HSC ITEMS Plan C'hcek Fee: suppl. PCT'ty PME Plan Check: $0.00 Permit Tee: Suppl. GaspTi.e PME Unit Fee: $87.00 PME Permit Fee: $44.00 Consiructiun Tax- arAdministrative AdministrativeFee: 1ADMIN $41.00 Work Without Permit? Yes (F) No $0.00 Advanced Planning F'eev: Travel Documentation Fee: ITRA VDOC $44.00 Strone Motion Fee: IRSEISMICR $0.50 Select an Administrative Item Bldg. Stds Commission Fee: IECESC $1.00 SUBTOTALS: $217.501 $0.00 TOTAL FEE: $217.50 Revised: 10/01/2011 OUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: ,7p6r-j<PERMIT # U U 6 OWNER'S NAME: r IPHONE# (-I Pl GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: ?9t ML o/^ n. no f C , a CITY/ZIPCODE: c'ILAA r�CP95 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontra^' " 1 Signature Date Please check applicable subcontractors and complete the following information: Signature 1/11/1 Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving lastering Plumbing %,-. 7 L Roofing Septic Tank Sheet Metal Sheet Rock Tile Signature 1/11/1 Date