08100146 CITY OF CUPERTINO , �
BUILDING DIVISION PERMIT CONTIR'' CT, R IN,FURMATI N
BUILDING ADDRESS: PERMIT NO. '
22731 STRVFN9 CREEKK BTAM MAqTPR
OWNER'S NAME: PERMITISSUEDATE
O. CONTROL NO.
408) 945-1000
ARCHrEECTtENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
u00 LICENSED CONTRACTORS DECLARATION Job Description F I hertbY affirm Nn I am ficuma d under provisions of Chapter 9(commencing
wiNSccuon]OOU)ofDivision
nj th imm�raae. r
REPLC SEWR LINE & INSTL PROP LINE CLEANOUT
ti 31
L....Cos Lic
F, Dao: mazmr
'��C onCHTfECTS D
I uMersund my plans Mall rte used ss pis mere,
�yV
a,
&j Lteensed Professional
3 GWNER-BUILDER DECLARATION
I k.by a?m Not I em exempt fru.w Cantractne.Lilco.Law far the
act following reason,(Salim.70IS.Busionss and Pmfead.m Cole:Any city or county
m_ which"ima a pcimit in consimm,afar.hnprOw.demolish or¢pair any structuou
yzy prioran it issue.¢.also oupomdin applicant for such permit.fik a ligned.atemcnt
F cwtlrta ma
liceedpmrsuant1.d.pm.;sioHnfwcamrasude.uccomLaw(Oupw9 Sq.FC Floor Area Valuation
Ho (emnmenNng with Sation]ODO)of Division 3.17 ft Buunmand Propulsions C.de)er
Nat M is exempt thounfran and w haus for w alleged exemption Any violation of O
Section 70313 by any sppliant turn Permit subjecta w applicant.a civil Ixmalty N APN Number Occupancy Type
nm come than five hunduW dollar(SS00).
❑Luowtw ofw propvry,m.y wPlaym with wagasswir.om compewtion, 34212119 .CMPLX
will do w want and w structure B notimendedm.frered foam(Soc.70".Bushmss Required Inspections
and Professions Cale:The Commucou s Lsanva Law does oat apply m owns an ownof q P
propertyvenobisilli, imthanes wean.andwM doessuchwork nimv!(ortnrougn hu
own employees,provhdedthan such mimprovementare not iouro unro@tad(wale11.
s-
builder Nebuildingnuimprovementohallwithin arc year or completion,wOwnerf
builder will have w burden of proving that K did not build or improve for puryoss of .
and'.).
1,as mmu r of the property.em exclusively contracting with licensed contractors m
controls the project(Sec.]014.Business add Professions Code:)The Cont actor's Li. v
close Law does not apply b an owner of pmPM7 who builds or improves carton.and,
who co.meta for such project with•conuacmr(s)lid pursuant m w Contracto'l
0 I me law.
❑Imo mempr under See .BdPCfar Nis rtsson
Owner Dau AN
WORKER'S COMPENSATION DECLARATION
I busby aVt.uMer pensltY of pmjury one of w folbwing dalanuorns
Ihave and w01 for
•co.37 te atheLntmConnnwrthn Wrform COmpeo-
ism,u providei fpc DY Salim 3]00 M w labor code.(o w perfomana of w
work for which this permil Is issues.
1 nave aM will maintain Worimi s Compensation Imuran.,,as required by Sado.
.f w Lanor Code.for w Nd.....1'w wort fon which this permit is issued.
My W.rte(s Co.,mussda a
on hisuranrtier and Policy nmb.,art
r.�T
u : _t
cmdcL C,[iory V Policy No.:GP( ood-1l
—)dO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This mc0on reed not be complemd Bw permit is forone hundrtd dollars($100)
or leas)
1 anify that in the perf.m u ce of w work for which this prmlt u issued.1 Mall not
employ,any person in any manner so as in become subject to w Wm1,On Compemssdon
I.of Califtrmia.Dam
Applicant
NOTICE TO APPLICANT:If, for making this Certifiam of Exemption.you Mould
baome subjm in w Wohcr's Commtation provisions of the labor Code,you most
Oforthwith comply with such provision Or this pemit Mall be dameA rtr.kcd.
zCONSTRUCTION LENDING AGENCY
l hereby aum that care is,cormmasm.lending agony rorty perim.Of
R:> w wort for which this permit is isurA(Ser.309],Civ.C.)
QLtMcts N,me
=z Inuleh Aldrtss .
U O 1 cmtify that i have mad this application and sum that w about infomatiun H
cortttt l agree in comply with all city and county.ilii",~••and sou laws rtofing to
.O buildingconsuuction,and hereby,uthorim opiaeautivrs ofthii city in enmrupOft w
r W alrovc-mendaned property,for inspection Purposes
(We)agree m save.indemnify,and kap humkts w City of Cupertino against v/
H fajl IiabilitW,judgme.ts.cmts add uK K.which may Nary way accnm against sad City
U Z in consequence of w granting of this pooh. c-
APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CE�REG��N //
——Sc h) 1 f 05' Re-roofs
Sig um of Applicm ontmcmf Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will w applicant m futum building OccupanLUM orhendle harudom material
as defined by w Cupertino Municipal Code.Chapmr 9.13.and the Hnldt and Safety
Clads.S.ed.n:ss32(.)t All roofs shall be inspected prior to any roofing material being installed.
❑Ya
Will "knot o/foto.building Occupant tial equipment Or d:sica which If a roof is installed without first obtaining an inspection,I agree to remove
it hvaNnns air conuminanu ss dc0rmd by the Bay Arca Air Quality Manegcmcnt all new materials for inspection.
LI
at �a
❑Ya
I havemad wda SecUusmaterials5533 rnmwunder Clupmr Q93afw Calling
no Health&Safety Cw a un
tia1255it in;m ll am125534ty in notify
tits,ocfw building
doe,not ewrondr Mae a tem.¢can it i,my rerp.nhiRny m.otiry w occupant or w
.qai. .tawnk met prior toisstrwteeof.CenifmamafOccupw.y. Signature of Applicant. Date
o J All roof coverings to be Class'{"or better
ne
OwauNmim r Dam'
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 34212119 .CMPLX
DATE ISSUED. . . . . . . : 10/23/2008
RECEIPT # . . . . . . . . . : BS000006442
REFERENCE ID # . . . : 08100146
SITE ADDRESS 22731 STEVENS CREEKK BLVD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CAMBRIDGE MANAGEMENT
ADDRESS . . . . . . . . . . : 22731 STEVENS CREEK BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JACK PERRY
CONTRACTOR . . . . . . . : BART ADAMS LIC # 25402
COMPANY . . . . . . . . . . : MASTER PLUMBING & SEWER INC
ADDRESS . . . . . . . . . . : 144 S WHISMAN DR
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94042
TELEPHONE . . . . . . . . : (408) 945-1000
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- - --- ---------- ----------
1BSEISMICR VALUATION 8, 000 . 00 0 . 80 0 . 00 0 . 80 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 . 78 0 . 00 102 . 78 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -----
CREDIT CARD 102 . 78 VISA
---------------
TOTAL RECEIPT 102 . 78
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
•
CITY OF CUPERTINO
REPREPI[PE/SEWER/MAIN SERVICE
• CUPEI�TINO PERMIT APPLICATION FORM
APN Date:
Building Address:
Z 2131 SiF-VEr►S C2.EO -
Owner's Name: Phone#:
cPMIN-1DGE rr� ANAGr�\G Flo l Z
Contractor A S+6� Lv M1� 11J(� Phone
Fax #:
Contact: Qy Phone #: 'ypg _OZ3
l T l Fax
Contractor License #: 8 2 3 Z(
Cupertino Business License #: 1
Job Description: 2C _pL-A t✓E
Wz'FGSaY` LI tqC CLE Argo4
Residential Commercial ❑
Valuation:
� � Ooo , GO
Project Size: Express Standard L Large F1 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
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
IBPWATER Install/alter Water Pipe P
IBPFIXTURE Plumbing Fixture P
IPGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
IPLMBLNCK Plumbing Plan Check P •
1PLMBINSP Other Plumbing/gas Insp. P
I 1TRAVDOC Travel &Documentation Fee B
1BUSLIC Business License B
Revised 6-16-08
•