12030131CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 891 ALDERBROOK LN
OWNER'S NAIVE: LOVVORN WILLIAM B AND CAROLE A
OWNER'S PHONE: 4082577567
❑ LICENSED CONTRACTOR'S DECLARATION
License Classes Lic. 8 _-?�CX;0 % `?)
Contractor \ b,\ ( t [?x i g f)I1S Date _S —n 1 Z
1 hereby affirm that l am licensed under the provisions of Chapler 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my 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 io 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 i
correct. I agree to comply with all city and county ordinances and state laws ating
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 ap icanl understands and will comply
with all non -point source regulations per theRupertino Municipal Code, Section
9.18.
Signalu Dater LLL
❑ OWNER - BUILDER DECLARATION
1 hereby affirm that 1 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 & Professions Code)
I, as 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 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 Cali fomia. If, after making this certificate of exemption,
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
cenify that 1 have read this application and state that the above information is
corect 1 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.
Date
CONTRACTOR: WATER QUALITY PERM IT NO: 12030131
PLUMBING
1860 ALMADEN RD DATE ISSUED: 03/27/2012
SAN JOSE, CA 95123 PHONE NO: (408)267 -9730
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: MAIN WATER SUPLY REPLACEMENT, PVC EXTERIOR
AND
TYPE L COPPER RE -ROUTE INTERIOR IN GARAGE TO JOIN
UP WITH EXISTING
Sq. FI Floor Area: I Valuation: $2700
APN Number: 36920008.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
1-t L
Date:
RE- ROOFS:
All roofs shall be inspected prior to any roofing material berg installed. If a roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
Signature of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I IAZARDOUS MATERIALS DISCLOSURE
I 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 2M32(a) should 1 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 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Seclionrq.F5505, 25533, and 25534,
Date:
CONSTRIICI'ION LENDING AGENCY
I 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
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36920008.00
DATE ISSUED........: 03/27/2012
RECEIPT #.:'....... : BS000016371
REFERENCE ID # ...: 12030131
SITE ADDRESS .....: 891 ALDERBROOK LN
SUBDIVISION ......:
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............: LOVVORN WILLIAM B AND CAROLE A
ADDRESS ..........: 891 ALDERBROOK LN
CITY /STATE /ZIP ...: CUPERTINO, CA 95014 -4613
RECEIVED FROM ....: MARTY SATALINO JR
METHOD OF PAYMENT
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
152.50
---------------
152.50
VOICE ID DESCRIPTION
-------- --------------- -------------
106 SEWER & WATER
507 FINAL PLUMBING
REFERENCE NUMBER
--------------- - - - --
AMEX
VOICE ID DESCRIPTION
--------------- ------- -- - ---
301 ROUGH PLUMBING
CONTRACTOR
.......: SATALINO,
MARTY LIC #
21526
COMPANY ..........:
WATER QUALITY
PLUMBING
ADDRESS ..........:
1860 ALMADEN
RD
CITY /STATE
/ZIP ...:
SAN JOSE,
CA
95123
TELEPHONE
.... -....:
(408)267 -9330
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
-- - - -- - -
lADMIN
-------------
HOURS
---- - --
1.00
- -- ----------
41.00
----------
0.00
-------
41.00
- -
-- -- - --- --
0.00
1BCBSC
VALUATION
2,700.00
1.00
0.00
1.00
0.00
1BPWSVCS
WATER SERVICE
1.00 22.00
0.00
22.00
0.00
1BSEISMICR
VALUATION
2,700.00
0.50
0.00
0.50
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
152.50
0.00
152.50
0.00
METHOD OF PAYMENT
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
152.50
---------------
152.50
VOICE ID DESCRIPTION
-------- --------------- -------------
106 SEWER & WATER
507 FINAL PLUMBING
REFERENCE NUMBER
--------------- - - - --
AMEX
VOICE ID DESCRIPTION
--------------- ------- -- - ---
301 ROUGH PLUMBING
CITY OF CUPERTINO
rM 'FEE ESTIMATOR- BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 891 Alderbrook Ln.
DATE: 0 312 7/2 0 7 2
REVIEWED BY: RDW
UNITS
APN:
BP#:
'VALUATION: $2,700
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1RPWS
PERMIT TYPE:
WORK
Main water supply replacement. PVC exterior - and Type L copper re -route interior in garage to coin u
SCOPE
with existing.
APPLIANCE / EQUIP TYPE
FEE ID
"Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Eler. Pe" mit Fee:
Water Service
iBPWSVCS
Omer E1cr. /nsp.
1
#
$22
Permit l,er:
Suppl. hisp Fee
PME Unit Fee:
$22.00
PME Permit Fee:
$44.00
Consnvction Tax
Administrative Fee: IADMIN
$41.00
Work Without Permit? O Yes 0 No
$0.00
Adounced Plamung Pecs:'
TOTALS:
Travel Documentation Fee: ITRAVDOC
$44.00
$22.00
$0.50
NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the prefintina in orinunon available and are only an estimate. Contact the Deal for addn 7 info.
FEE ITEMS (Fee Resolution 11 -053 E(! 711111)
,lleadt. Mon ChecE -
"Plumb. Plan Check 0.0 1 hrs $0.00
/:lea. Plan Clark
meth. Perwit Fee:
Plumb. Permit Fee: IPPERMIT
Eler. Pe" mit Fee:
Other Me, h. /n.rp.
Other Plumb Insp. 0.0 hrs $44.00
Omer E1cr. /nsp.
,Idarh. My. Fee:
Phunh. hup. Fee:
Eler. /rrcp. Fee:
NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the prefintina in orinunon available and are only an estimate. Contact the Deal for addn 7 info.
FEE ITEMS (Fee Resolution 11 -053 E(! 711111)
FEE
QTY /FEE
MISC ITEMS
Plan Chuck Fee:
.Cupp/. PC Feu
PME Plan Check:
$0.00
Permit l,er:
Suppl. hisp Fee
PME Unit Fee:
$22.00
PME Permit Fee:
$44.00
Consnvction Tax
Administrative Fee: IADMIN
$41.00
Work Without Permit? O Yes 0 No
$0.00
Adounced Plamung Pecs:'
Travel Documentation Fee: ITRAVDOC
$44.00
Strong, Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
131dg, Stds Commission Fee: IBCBSC
1 $1.00
SUBTOTALS:
$152.50
$0.00
TOTAL FEE:
$152.50
Revised: 1/19/2012
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 _ M I
(408) T77 -3228 • FAX '(408) 7T7-3333 • buildina(D)cuoertino.DrD
Iq PLUMBING F1 MECHANICAL nELECfRICAL I7MISCELLANF.c)us
PROTECT ADDRESS �O
APN f�
U
. / �i 7-70g
OWNER NAME (J` -` PHONE - „��I /7 ,? 1
EhtptLOL
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STREETADDRESS(�n �O
STA ZtP
FAX
CONTACT NAME
PHONE .� A ^ ^�
LSJ I
E -MAIL- lMkl 1. — ^A3
w - a l
STAEiT ADDRESS 1
C
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FA%
❑ OWNER ❑OWNER- BUDDFJI ❑ OWNEAAGENT CONTRACTOR ❑LONTRACIORAGENT ❑ ARcHrrELT ❑ENGINEFR ❑ DE'/ETDPER ❑TENANT
CONTRACTOR NAME
LICENSE NUMBER rt,
`�'
U
SETYPE
ID
BUS. 11C
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY. STATE, ZIP
PHONE
ARCHR'ECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC N
COMPANY NAME
E -MAD.
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF 12REM m DUPLID( ❑ MULTFFAMTLY
BUDDING: ❑ COMMERCIAL
PROTECT IN WDDL ND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROIECr w
FLOOD ZONE
❑ YES
❑ NO
IS THE BLDG AN ❑ YES
EICLITII HOME/ ❑ NO
DESCRIPTION CF WORK
/LS
t�T ��\ \ C
S 1T \ C9 '•
TOTAL VALUATION: J `� /' �/' �� —
RECEIVED BY:
By my signature below, I 6wify to each of the fallowing: I am the property owner or authorized agent to act w the property owner's behalf. I have read this
application and the information I have provided is d the D ' tiw of Work and verify it is accurate. I agree to comply with all applicable local
mdinances and state laws relating to building construed ariu represrn ves f Cupertino to enter the above - identified property for inspection pu(poses.
��
Signature of ApplicanNAgeot Dam:
SUPPLEMENTAL INFORMATION REQUIRED
OMCE USE ONLY
u
OVER- TAE - COUNTER
Y
❑ EXPRESS
V
m
U
❑ STANDARD
3
❑ LARGE
❑ MAJOR
MEPMtscelpp_2011.doc revised 0621/11
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