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10030088 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18630 CRABTREE AVE CONTRACTOR:JD PLUMBING PERMIT NO: 10030088 OWNER'S NAME: STACY WILSON 270 UMBARGER RD STE 66 DATE ISSUED:03/15/2010 iER'S PHONE: 9732355000 SAN JOSE,CA 95111 PHONE NO:(408)646-3266 O- LICENSED CONTRACTOR'S DECLARATIONr- / BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class 0 --3& Lic.# p Q Cl 1 3 � MECH r RESIDENTIAL r- COMMERCIAL� Contractor % Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACING SEWERLINE FROM HOUSE TO STREET (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 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: do 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 1W 'Ift permit is issued. APN Number:37526058.00 O upancy Type: 14 APPLICANT CERTIFICATION NA IM 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 PERMIT EPI ORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN .8 ` .S PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 costs,and expenses which may accrue against said City in consequence of the DAYS FRO 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 Issued b Date_ 9.18. �. Signature Date RE-ROOFS: Lr OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this 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'sOw r a oriz4gent: j Compensation laws of California. If,after making this certificate of exemption,I Date: /S 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save i mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses whiJrEjons ccrue against said City in consequence of the granting of th i). ally,the applicant understands and will comply I understand my plans shall be used as public records. with all n points rcper the Cupertino Municipal Code,Section 9.18• Licensed Professional Signature "f M~w Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37526058 . 00 DATE ISSUED. . . . . . . : 03/15/2010 RECEIPT #. . . . . . . . . : BS000009943 REFERENCE ID # . . . : 10030088 SITE ADDRESS . . . . . : 18630 CRABTREE AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER STACY WILSON ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JUAN LUIS DIAZ CONTRACTOR . . . . . . . : JUAN DIAZ LIC # 30298 COMPANY . . . . . . . . . . : JD PLUMBING ADDRESS 270 UMBARGER RD STE 66 CITY/STATE/ZIP . . . : SAN JOSE, CA 95111 TELEPHONE . . . . . . . . : (408) 646-3266 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- -------------. ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 4, 000 . 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 . 50 VISA --------------- 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 CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEI�TINO PERMIT APPLICATION FORM Date: Building Address- 1V630 ddress:63v Li� �': c� Phone#: Owner's 1; 73 . 226 Contractor: // ' Phone#: IGC �''Z'1 Fax#: Contact: - Phone#: � Fax#: Contractor License#: Z Cupertino Business License#: Job Descripti Residential '+ Commercial ❑ Valuation: Project Size: Express F1 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 building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial Gas Piping System P 1-4 Outlets 1 BCBSC Cal Bldg Standards Commission B ALL PERMIT TYPES Fee 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO `` REPIPE/SEWEI�JMAIN SERVICE Of CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group P 1BCBSC Cal Bldg Standards Commission B ALL PERMIT ( Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1 BPGAS Gas Piping System 5+ Outlets P lPPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1 PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B Community Development 10300 Torre Avenue { Cupertino CA 95014 F: Telephone(408)777-3228 Fax(408)777-3333 CITY OF 'UPEkTINO Bundin De artmI JOB ADDRESS: PERMIT OCA �� 1163 U L Ana., OWNER'S NAME: S G€/�� -� PHONE # o w -3 Z 6 L GENERAL CONTRACTOR: 12t n FAX# I am not using any subcontractors: Date Signature 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