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10090265 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20025 CEDAR TREE LN CONTRACTOR:GREAT AMERICAN PERMIT NO: 10090265 PLUMBING CO INC WNER'S NAME: JACK&BETTY ISHIKAWA P O BOX 26942 DATE ISSUED:09/29/2010 OWNER'S PHONE: 4082535382 SAN JOSE,CA 95159 PHONE NO:(408)279-1515 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class ` 3 Lic.#�(1)(ai 2:77 �± INSTALL PROPERTY LINE CLEAN OUT , Contractor /?PAT"AAM iepw &KWJ1jPate q:!a—/ I hereby affirm that I am licensed under the provisions of Chapter 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 to self-insure for Worker's oil Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: luation:$2200 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 APN Number-P 0 0 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT4WPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating; WITHIN 18 PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS T CALLED INSPECT ON. �� indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Issued by: Date: granting of this permit. Additionally,the applicant understands and will comply with all non- oint source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: gnat Date � All roofs shall be inspected prior to any roofing material being installed.If a roof is _ installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Date: Signature of Applicant: I hereby affirm that I am exempt from the Contractor's License Law for one(if the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensatio r, 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 tc HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S do 25 , 5533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen . Date -aye 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 CONSTRUCTION LENDING AGENCY 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 mm ist I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ,n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION .emnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF' CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: B].k: Lot: APN 33.624001. 00 DATE ISSUED. . . . . . . : 05,/29/2010 RECEIPT #. . . . . . . . . : BE'000011590 REFERENCE ID # . . . : 1( 090265 SITE ADDRESS . . . . . : 2CO25 CEDAR TREE LN SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CLPERTINO IMPACT AREA . . . . . . OWNER JP.CK & BETTY ISHIKAWA ADDRESS 2CO25 CEDAR TREE LN CITY/STATE/ZIP . . . : CLPERTINO, CA 95014 RECEIVED FROM . . . . : TFE GREAT AMERICAN CONTRACTOR . . . . . . . : CCRPORATION LIC # 18061 COMPANY GREAT AMERICAN PLUMBING CO INC ADDRESS P O BOX 26942 CITY/STATE/ZIP . . . : SPN JOSE, CA 95159 TELEPHONE . . . . . . . . : (408) 279-1515 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 2, 200 .00 1. 00 0 .00 1 . 00 0. 00 1BSEISMICR VALUATION 2, 200 .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 ----------------- --------------- -------------------- CHECK 106 . 50 116388 --------------- TOTAL RECEIPT 106 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING a CITY OF ir"UPERTINO REPIPE/SEWE: SERVICE CUPCM OF EkTiNO PERMIT APPLICATION FORM APN # Date: 34 co I .W Building Address: p OO;L5 C E19M 1„_ em L A vc Owner's Name: Phone#: Contractor: Phone#: .1-let-IS-)5 pAT N-t(5eto4 Contact: Phone #: SES Fax #: Contractor License#: G G S Cupertino Business License* Job Description: Zivs, 111Ae00Pt?^r <<%vE (�I_XO_A v 19 uT Residential ?11Commercial ❑ Valuation: �;06 Project Size: Express Standard ❑ Large 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 bt.ilding P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Stanc.ards Commission, B ALL PERTNUT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 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 JOB ADDRESS: e25 PERMIT# U OWNER'S NAME: tZ "— PHONE# t�0>Lr"0�7 GENERAL CONTRACTOR: eN US LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY?and CTORS INSPECTION(S) HAVE OBTAINED AHCITY OF CUPERTINO UNTIL THE GENERAL CONTRACTOR AND ALL BUSINESS LICENSE. I am not using any subcontractors: Date nature Please check applicable subcontracete the following information: SUBCONTRACTOR FBUSINESSNAME 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