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09100088 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10642 N PORTAL AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100088 OWNER'S NAME: RICHARD GREGERSEN DATE ISSUED: 10/14/2009 l -",R'S PHONE: 4083955599 , PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.# I— r MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE INMAIN HOUSE HOT AND COLD (commencing with Section 7000)of Division 3 of the Business&Professions WATER LINE,GAS Code and that my license is in full force and effect. LINE&TANKLESS WATER HEATER• 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 Sq.Ft Floor Area: Valuation:$5884 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31632054.00 Occupancy Type: APPLICANT CERTIFICATION 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. 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. Issued by; Date:,/4;__/ . Signature Date CJ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to constrict the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation;as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 1 certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I O o uthorized a Q become subject to the Worker's Compensation provisions of the Labor Code,I m Date: � p forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address nify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signat6R�!—�'c'�`'�c4 ate - �3_.meg CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 31632054 . 00 DATE ISSUED. . . . . . . : 10/14/2009 RECEIPT #. . . . . . . . . BS000008910 REFERENCE ID # . . . : 09100088 SITE ADDRESS 10642 N PORTAL AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : RICHARD GREGERSEN ADDRESS 10642 N PORTAL AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2449 RECEIVED FROM RICHARD S GREGERSEN 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 ---------- ------------- ---------- ---------- ---------- ---------- ---- 1BCBSC VALUATION 5, 884 . 00 1 . 00 0 . 00 1. 00 0 .00 1BPWATER UNIT 1 . 00 42 . 00 0 . 00 42 . 00 0 .00 1BPWSVCS WATER SERVICE 1 .00 21 . 00 0 . 00 21. 00 0 . 00 1BSEISMICR VALUATION 5, 884 . 00 0 .60 0 . 00 0. 60 0 . 00 1PGASRES OUTLETS 1. 00 63 . 00 0 .00 63 . 00 0 .00 1PPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 . 00 1PRWHEATR UNITS 1. 00 25. 00 0 . 00 25 . 00 0 .00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 236 .60 0 . 00 236 . 60 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 236 .60 VISA --------------- TOTAL RECEIPT 236 .60 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING oql 000 CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPF ERTINO PERMIT APPLICATION FORM APN # Date: Building Address: 10 & ,A 2 r1. Owner's Name: Phone#: �G E E�tzs�.J c4 3qS-5SIR a g4. 4 Contractor: Phone#: 65o_-t-+t - z 4 c1 C., L �z-� !S e4::L2vrA tS.rl Fax #: 40 ,-345-��b44 Contact: Phone#: 65o k— 2 Aa 6 1_.pAz.,V-J -,A-M,4 A Fax#: Contractor License#: vo'3�5 Q 3 Cupertino Business License#: Job Description: c..ri c q. 1 r� M Ftp r.1 ri o S 4. ir-la-C P..� fl G o �-� w a►-CF tz �4� Residential ❑✓' Commercial ❑ Valuation: Project Size: Express Standard 0 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 1PCSEWER Commercial building P 11CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial Gas Piping System P _ 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO `' REPIPE/SEWER/MAIN SERVICE CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES / 1BSEISMICR Seismic Residential P I 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1 PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1 BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P f 1PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P / 1PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P f 1TRAVDOC Travel &Documentation Fee B I 1 BUSLIC Business License B Community Development 10300 Torre Avenue s Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 XPEkTINO Building Department JOB ADDRESS: PERMIT # l fJ(o �-F'2. til, �o t=-fs►r� �t 09 C)o 92 OWNER'S N ��• - �! PHONE #3s- se- GENERAL CONTRACTOR: L s FAX # 3�tS- 8.Q1f I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date