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12010116CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: [0235 UNIVERSITY WAY CONTRACTOR: FIX IT PLUMBING PERMIT NO: 12010116 OWNER'S NAME: HO TERRY Y AND ANNIE T 15201 CAMELOT DR DATE ISSUED: 01/18/2012 OWNER'S PHONE: 4088938555 SAN JOSE, CA 95132 PHONE NO: (408) 509-2772 ❑ INCENSED CONTRACTOR'S DECLARATION License Class 3 Lrc.# / 06 C� IS - Contractor Date !!/Z / Z I hereby affirm that I a€rr licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that illy license is in full force and effect. I hereby affirm under penalty of perjury one of the following two 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. 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. Signature i / Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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 &r. Professions Code) t, is owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business &: Professions Code). I 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 3706 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 is to become subject to the Worker's Compensation laws of California. 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 arid 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. Signature Date BUILDING PERMIT INFO: BLDG' ELECT 3 PLUMB ,� iµµ ,....... MECH £ RESIDENTIAL' COMMERCIAL JOB DESCRIPTION: COPPER RE -PIPE FOR DUPLEX(1 BATHROON4 IN EA. UNIT).REPLACE SEWER AND CHECK FOR SEWER PROPERTY LINE CLEAN OUT A - k, Sq. Ft Floor Area: 0 1,%` f,~.on: $10000 APN Number: 32623040.00 ' 4 ,,,fk)ccupancy Type: PERMIT EXPIS`WORK IS NOT STARTED WITHIN 180 1+ PERMIT ISSUANCE OR 180 DAYSFQLAST CALLED INSPECTION. i_ - Issued by: --- ate/%7 c '-? RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining all inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I 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 authorized agent: Date: —Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ti 7 ITEMS OF 8 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32623040.00 DATE ISSUED.......: 01/18/2012 RECEIPT #.........: BS000015770 REFERENCE ID # ...: 12010116 SITE ADDRESS .....: 10235 UNIVERSITY WAY SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: HO TERRY Y AND ANNIE T ADDRESS ..........: 10235 UNIVERSITY WAY CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM ....; FIX -IT PLUMBING CONTRACTOR .......: JUAN ALCANTARA LIC # 30728 COMPANY ..........: FIX IT PLUMBING ADDRESS ..........: 15201 CAMELOT DR CITY/STATE/ZIP ...: SAN JOSE, CA 95132 TELEPHONE ........: (408) 509-2772 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 10,000.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 10,000.00 1.00 0.00 1.00 0.00 1PPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1PREPPIPE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1PRSEWER UNITS 1.00 22.00 0.00 22.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 TOTAL PERMIT ---------- 197.00 ---------- 0.00 ---------- 197.00 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 316.00 --------------- 316.00 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER REFERENCE NUMBER -------------------- #1359 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 506 GAS TEST 507 TUB & OR SHOWER FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10235 university way. 77 DATE: 01/18/2012 REVIEWED BY: bobs. APN: BP#: Piping, Area J 1 PREPPIPE -VALUATION: 1$10'000 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Dulex USE: I Sewer, Building IPRSEWER PENTAMATION 1 RPDP I PERMIT TYPE: WORK copper repipe for duplex i bath each. Replace sewer and check for sewer property line clean out. SCOPE El APPLIANCE / EQUIP TYPE FEE ID 77 QTY UNITS BP FEES Piping, Area J 1 PREPPIPE 1 # $44 PME Plan Check: Sewer, Building IPRSEWER 1 # $22 El PME Unit Fee: $66.00 PME Permit Fee: $44.00 TOTALS: $41.00 Work Without Permit? 0 Yes G No $66.00 ATOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School TIhiripf at.- i Thou. foac gire havod an tho tirplininary infnrmatian available- and are only an estimate. Contact the Dept for addh 7 info. IS FEE ITEMS 77 Plumb. Plan Check I O.OThrs $0.00 IPlumb. Permit Fee: IPPERMIT Other Plumb Insp. El hrs $44.00 MISC ITEMS ATOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School TIhiripf at.- i Thou. foac gire havod an tho tirplininary infnrmatian available- and are only an estimate. Contact the Dept for addh 7 info. IS FEE ITEMS FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 El PME Unit Fee: $66.00 PME Permit Fee: $44.00 Administrative Fee: JADMIN $41.00 Work Without Permit? 0 Yes G No $0.00 Travel Documentation Fee: I TRA VDOC $44.00 Fee: IBSEISA41CR $1.00 Select an Administrative Item t IBCBSC $1.00 SUBTOTALS: 1 $197.001 $0.001 TOTAL FEE: $197.00] Revised: 1 /01 /2012 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST J JOB ADDRESS: 1(223s PERMIT # / OWNER'S NAME: 4Ai91 PHONE # 5e) 9 - 2 7 72 GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: /QK CITY/ZIPCODE: S/3 *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 subcontractors:�- Signature Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature 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 Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(d�cupertino.org /"26/- 0// V(.,,'. T"r_ M KA7ruAN7rAT 71=T I:r-nTrAT F-1 MTR rPT T A- FMnTIS MEP MISIC PROJECT ADDRESS //� 2 r _' / L• , 23 L L -PSI i v -J i, �� y / v OWNER NAME PHO �j C C� �� 0 M7 E-MAIL STREET ADDRESS CITY, STATE, ZII�— �' FAX CONTACT NAME % �C s PHONF(%,L' )S -el 7 7 7 2 E-MAm STREET ADDRESSA CITY, STATE, ZIP FAX ❑OWNER ❑OWNER-HUn DER ❑OWNER .4 GENT CONTRACTOR El CONTRACTOR AGENT ElARCHITECT ❑ ENGINEER 11 DEVELOPER 11 TENANT CONTRACTOR NAME --LICENSE _1'e"j NUMBER ,:: LICENSE TYPE BUS. LIC # COMPANY NAME ` }N� L EMAIL STREET ADDRESS/ Z- , " L CITY. STATE, ZIP PHO � C� c ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN YES FLOOD ZONE ❑ NO IS THE BLDG AN YES IICHLER HOME? ❑ NO DESCRIPTION OF WORK / f — c` Cit TOTAL VALUATION: L c --Z:> —�' RECEIVED BY:L-- LDb By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct., have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection pu{poses. Signature of Applicant/Agent: Date: .1 - / LfZ (SUBRESMENTAL INFORMATION REQUIRED OFFICE USE ONLY a U W U a ❑OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 0 612 1/11 I a