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10100140 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10631 CARVER DR CONTRACTOR:COUNSIL PLUMBING PERMIT NO: 10100140 1127 SOMERSET DR DATE ISSUED: 10/19/2010 OWNER'S NAME: GUADAL•.JPE LECHUGA SAN JOSE,CA 95132 PHONE NO:(408)272-2272 NER'S PHONE: 4086903146 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class(_,',- 5 (o Lic.# q 2'6 7 6-6' MECH r RESIDENTIAL r COMMERCIAL r Contractor r O(,.114-J L Pfg.44,- Date 110-- 'Ci _10' JOB DESCRIPTION:PULL APPROX 30FT SEWER LINE INSTALL PROPERTY I hereby affirm that I am licensed under the provisions of Chapter 9 LINE (commencing with Section 7000)of Division 3 of the Business&Professions AND HOUSE CLEAN-OUTS Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarationsI 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$M TAV�6 I have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$3500 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: permit is issued. APPLICANT CERTIFICATION i�t)A Z-1 APN Number:37534047.00 Occupancy Type: 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 relatin;; to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9'18' / /G2 r_10 �� f Issued by: Date: < Date Signature ��✓,�•'^-r `[ V OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one A All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensatic n, inspection. 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 construct 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 declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I sha 1 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. if,after making this certificate of exemption, Ow � rt: 0 become subject to the Worker's Compensation provisions of the Labor Code,I n ust forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name 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,judgment.,, and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Sectior I understand my plans shall be used as public records. 9.18. Signature Date Licensed Professional CITY CF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Elk: Lot: APN . . . . . . . . : -7534047 . 00 DATE ISSUED. . . . . . . : 30/19/2010 RECEIPT #. . . . . . • • . : LS000011786 REFERENCE ID # . . . : 1.0100140 SITE ADDRESS :.0631 CARVER DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER GUADALUPE LECHUGA ADDRESS : 0631 CARVER DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM 'IALERIE COUNSIL CONTRACTOR . . . . . . . : 14ICHAEL COUNSIL LIC # 30754 COMPANY COUNSIL PLUMBING ADDRESS . . . . . . . . . . : L127 SOMERSET DR CITY/STATE/ZIP . . . : 3AN JOSE, CA 95132 TELEPHONE (408) 272-2272 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ------- 1BCBSC VALUATION 3, 500 . 00 1 .00 0 .00 1 . 00 0 .00 1BSEISMICR VALUATION 3, 500 . 00 0 .50 0 .00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRSEWER UNITS 1. 00 21 . 00 0 . 00 21. 00 0 .00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 .00 -----42_00 ------0_00 ---------- ---------- TOTAL PERMIT 106 .50 0 . 00 106 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------- CREDIT CARD 106 .E0 VISA -------------- - TOTAL RECEIPT 106 .E0 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- -------------------------- -- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: $3,500 PA-PERMITTYPE: Plumbing Permit P1,AN CHECK TYPE: Alteration /Addition / Repair PRIMARY !)1'_,F TRE-NTAMAYTP11N 1 RPSS USE: SFD or Duplex ;��} �,_; PERMIT TE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $21 TOTALS: $21.00 Plumb.Plan C Teck 0.0 hrs $0.00 f r t'��f�c`1'-"'k Tlumb.Permit Fee: IPPERMIT Other Plumb Iisp. 0.0 hrs $42.00 t�rrr 'I1 �t. NOTE: TheseTs are based on the relimina in ormation available and are onl o. an estimate. Contact the Dept or addn'l info. -fi FEE ITEMS (Fee Res ttion 09-051 Ejf. '/1:70) FEE QTY/FEE MISC ITEMS 1/all Cl1f cA' Slipp1. PC Fe PME Plan Check: $0.00 Permit Fcc.-- S!/p111. 11Isp F(-c PME Unit Fee: $21.00 PME Permit Fee: $42.00 Consmtrcrion Tax F ,.:oustical Rc+Ot.1v Fec>: Work Without Permit? 0 Yes No $0.00 Plctnrrix�r 7=tic's: Travel Documentation Fee: I TRA VDOC $42.00 i Stron,Motion Fee: $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $106.50 $0.001TOTAL FEE: 1 $106.50 Revised: 9/29/2010 1 0 t CITY OF CUPERTINO REPIPE/SENNER/MAITN SERVICE CUPEkT1NO PERMIT APPLICATION FORM APNh# r-� _ Date: 1 `� Q� Building Address: ' Li a Y2— Owner's Name: Phone#: Contractor: vPhone#: -iz ; -Z 7 2 Z- I L_ Fax #: Contact: , �'f; ,. f, I Phone -7 : - % 7 Fax #: �l�� 2- - 0-7 1-0, Contractor License#: Cupertino Business License #: Job Description: P A 9P r, c 3 c C f, ' (.---4y l .s1 C -c-- - c•,k A/A l . S cr Residential Z Commercial ❑ Valuation: J �� Project Size: Express Standard E Lar€,e ❑ 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 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg St�mdards Commission, B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09