08100163 CITY OF CUPERTINO -
BUILDING DIVISION PERNHT fkCdFIITRA f)R IN O T aN,
BUILDING ADDRESS: PERMIT NO.
10181 EMPIRE AVE TBD - TQ BE D
OWNER'S NAME: PERMIT ISSUE DATE
p SA CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
RE-PIPE, SEWER- GAS; NOTE: 'BLDG ELECT PLUMB MECH
Jop LICENSED CONTRACIDR'S DECLARATION ADVNCDD PLMBING Job Description
�uZ I bomby"m that l am licensed under Provisions of Chapkr 9(commcncingp
n< with Section?=)ufDivishm 3 of the Business and Plef=ssirm Code.and my Ike=is
< in full forte ave pQ a
j _ lleenm tlw Lin g
DamComracCL
ARCHITECTS OFLLAR ION
I urtlersu«I my Pius Nmll the u0)(as public mcoNa
p,(7
g C Licensed Professional
OWNER-BUILDER DECLARATION
E I mosso alarm o n I a1.exempt from the Clarn(endo Co License:Any c law for the
0 o following mesa emit 0 co 1.d.Business and Pmfessions Cale:Any city or county
which requ'uus n Prsmk m csnnmcL ape.improv.h per W.«¢pair aY tatunure
2
prior¢its issumcaalsomcquims dieapplicantfor achpermi'¢itemfile s gnwatskmcm
Y ons,he wpursuit 7000)of Division
3 of Busin«SLJcenselaw(CMptm9 Sq.FL Floor Area Valuation
yFg (commencingheismwithhewromon and
of hands
ans for aftheeged caampl Prof inti Code)of
Q�� that bo k exanpt therefrom and tbo baso f«tbo alleged essmptioa MY violation of
Section 7031.5 by any applicant for a Permit subjects the aPPikul to a civil penalty of APN Number Occupancy Type
cot mart than five hundred dollars(55WIL
I,uownerof Die propmy.«my employ with wguuO¢vsole emnpew0on,
add do tbo w«k.0 d e Wumare la net s Lt. maw toad et apply 70a.Bud r of -
ue property
Cwr:Tin Cameron.Liman Law dam ort appy lf rt owner is Required Inspections
own
wo Wilda i improms thereon.mat,sew who menu in work oroffred(hough h1.
awn emplsycea,provided that such improvements are not ear ef�arofkrrd(«sale 11.
builder the anad,e ser hes of pront4alt withinutyear ofmmPktifrtheaw«r-
Wilder .will low(k beth¢of proving Nu bo did net buile at improve for purpose of
ale.).
❑1,as owner of the property...exclusively contracting with licensed mmramm an
' cousauct the projM(Sec-70x.Butinw sew ProkSVons Cade:)710)Conaxmr'i Li.
cow Lawes f nus appy m ts owner of proper(hobo sed poor imProw Commeand.
LMnse Lacu far such projects with a canmsmr(s)licensed puraunt m Ne Csnuume,
License Law.
❑lam exempt undo See .B&PCf«shin¢assn
Owner Due
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perj« rc y aof ft fallowing dec ansa e,
1 have and will maintain a Certificate of Consent to self-blurt f«Wallace,Comped.
.u Provided for by Sectim 3700 or(x Labor Code,for the performance of tbo
wort for which Nu Permit is issued.
❑1 have and will maintain Worimrs Compensation Insurance,as required by Section
37M of the labor Code.for Nc pertedeere ofthe work for which thi,Permit u L—vvj '
My Wd W. =--'r CompensWo�n�Tnsu�r.��pcarrier and Polity n .be 770
Cagier. . 7*-m Aip Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibla mom rred mat cc«opkkd if We pcmo Is f«onthunthrd dollars($100)
or lea)
1 cenifv(0)t la the prrfmma«e N We wmk for which Nis permit u handed.I shall am
employ any peran in my manner an as to become abject to the Workers'Compensation
Laws of Cali(omia.Due
Applicant
NOTICE TO APPLICANT.If,after making this Ceeificate of Exemption,you should
become abject m the Workers Compensation previsions of the I.ah«Codc.you most
O forthwith comply with such prou«
visimthis Permit shall he dremed remand.
z 55 CONSTRUCTION LENDING AGENCY
F-r.�. I hereby alum due Vert is a construction lending agency for the performance of
a the work for which this permit u iss«d(Sec.3097,Civ,C.)
W Ca Lemices Name
5 z Lander,Address
U Q I certify that 1 have mad this application and fume that the above information is
D,E' torten.l agren to comply with all city and county ordinusw and auk laws reading a,
.0 Wilding construction.ave hereby audum a mpremmadves of the city to ener upon thc
Wmove-mendaned property for inspection puryorca
P.
(we)agree to sew,indemnify ad keep harmless the City of Cupertino against(We)I.n fjl liabilities,Judgmcnk,caw andespevu which mryin any'+'aY accme sgaiulsaid Cityains
C)? APPLr IC NT UN ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATIONS.
Re-roofs
$ignuurt AppliwHAZARDOU De
xAZARDOUSM ALSd.on.osunE Type of Roof
Will the applicant m Potuni Wilding ocmpat rmre or handle harallous material
as defined by the Cupertino Municipal Code.Chapter r 9.11.sethe Hglth and Safetycode,Section 255310)7
❑Ye ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or futurt Wilding occupant use equipment Of&Vie=which If a roof is installed without first obtaining an inspection,I agree to remove
a Wmine air cmmminsnts as defined by the Bay Ama Air Quality Management all new materials for inspection.
str 0)t
❑Ya ❑No
I haw read tlk hmaolods materials requirements under Chapter 6.95 ofthe Califm-
nixHcaldt&Safety Code,Sections 15505,15533 and 15534.1 undcrumnd Nn ifthe Wilding
does WE cmventiY haw a went that it u my mgwnsibililY to oddly dre occupant at the
mquimhicbmuobcpre 'sr umnccafaCanificekofOcevpary
Signature of Applicant Date
Owner or me
mind age p,k All roof coverings to be Class'%W'or better
CITY OF CUPERTINO
8' ITEMS OF 11 PERMIT RECEIPT. OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32624049 . 00
DATE ISSUED. . . . . . . : 10/27/2008
RECEIPT # . . . . . . . . . : BS000006464
REFERENCE ID # . . . : 08100163
SITE ADDRESS . . . . . : 10181 EMPIRE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JANET WOLFF
ADDRESS . . . . . . . . . . : 10181 EMPIRE AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1204
RECEIVED FROM . . . . : A.R.M. S.
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
• FEE ID UNIT 'QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
------ ------------- ------ -------- ---------- --- - ----------
1BPWATER UNIT 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1BPWSVCS WATER SERVICE 1 . 00 20 . 40 0 . 00 20 . 40 0 . 00
1BSEISMICR VALUATION 11, 000 . 00 1 . 10 0 . 00 1 . 10 0 . 00
1BUSLIC FLAT RATE 1. 00 110 . 00 0 . 00 110 . 00 0 . 00
1PGASRES OUTLETS 1 . 00 61 . 19 0 . 00 61 . 19 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 335 . 46 0 . 00 335 . 46 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
--- --------------------------- -------- - ---------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING -
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
0?/C) o � 3
S,am.-
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEklfINO PERMIT APPLICATION FORM
APN# � � % v , / � - 0 � Date:
Building Address:
Owner's Name: Phone#:
A�:t L�.>a lFF
Contractor: yo I A N,0 9 AC � C a A R, KA , � Phone#: c,ya8 qg- / S 1 y
Prc�v��� �tst��L .e -r' a���•' 1
Contact: JRso� y�t� �c�J Phone#: �aS YON&
I Fax #:
Contractor License#: Cl � �
Cu ertino Business License#:
Job Description: P IPC t � Gl A S—
Residential Commercial ❑
Valuation: II
Project Size: Express Standard ❑ Large 0 Major
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.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
IPCSEWER 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
CITY O
CUPEkTINO FEE SCHEDULE •
Quantity Fee ID Fee Description Fee Permit Type
Group
iPRREPIPE 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
IBPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
r 1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P •
IPLMBINSP Other Plumbing/gas Insp. P
/ 1TRAVDOC Travel &Documentation Fee B
/ IBUSLIC Business License B
r
Revised 6-16-08
•