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10020133CITY OF CUPERT BUILDING ADDRESS: 21651 LINDY LN OWNER'S NAME: NELSON DARRELL WNER'S PHONE: 4082537095 LICENSED CONTRACTOR'S DECLARATION 1 License Class Lic.# Contractor ate Z �� I hereby affirm that I am licensed under Me "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. [NO BUILDING PERMIT I hereby affirm under penalty of perjury one of the following two declaration s: 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. APPLICANT CERTIFICATION 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 relat ng 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. tionally, the applicant understands and will comply with all non -point sa regulations pee theG°pertino Municipal Code, Section 9.18. ou / / // L] CKVNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for oric of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensat on, 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 o 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 sha II 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, become subject to the Worker's Compensation provisions of the Labor Code, I n lust forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 rela ing to building construction, and hereby authorize representatives of this city to ente upon the above mentioned property for inspection purposes. (We) agree to save demnify and keep harmless the City of Cupertino against liabilities, judgments, sts, and expenses which may accrue against said City in consequence of the granting of this permit. dditionally, the applicant understands and will comply with all non -points r regulaf' s r the upertino Municipal Code,,Section , 9.18. Signature Date CONTRACTOR: ALLSTAR PLUMBING I PERMIT NO: 10020133 326 PHELAN AVE DATE ISSUED: 02/24/2010 SAN JOSE, CA 95122 PHONE NO: (408) 230-5569 JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL SEWER LINE REPLACEMENT T Sq. Ft Floor Area: on: $9300 APN Number: 35622015.OQpw. V& ® W1 Occupancy Type: PE$E WORK IS NOT STARTED WIT AYS OF PERMIT ISSUANCE OR 180 DA LAST CALLED INSPECTION. Issued by: Date: C/ �'Z/ RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Apea Air Quality Management District I will maintain compliance with the Cup lino Muni ' al Code, �hapter 9.12 nd the Health & Safety Code, Sections 5, 25533 n 2553. Owner or authorized agent Date• CONSTRUCTION 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 Professional 4 ITEMS OF 4 CITY OF �UPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35622015.00 DATE ISSUED.......: 02/24/2010 RECEIPT #......... BSC00009814 REFERENCE ID # 1OC20133 SITE ADDRESS 216151 LINDY LN SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNERNE:�SON DARRELL ADDRESS . 21551 LINDY LN CITY/STATE/ZIP CU?ERTINO, CA 95014 OPERATOR: SylviaM COPY # : 1 RECEIVED FROM •" : DU ARTERTADEVBINLIC # 22189 CONTRACTOR ...... COMPANY ALLSTAR PLUMBING ADDRESS 326 PHELAN AVE CITY/STATE/ZIP SAN JOSE, CA 95122 TELEPHONE (408) 230-5569 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT ---------- THIS REC- --NEW -BAL- ---------- 1BCBSC 1BSEISMICR 1PRSEWER 1TRAVDOC ------------- VALUATION VALUATION UNITS FLAT RATE ---------- 9,300.00 9,300.00 1.00 1.00 ---------- 1.00 1.00 21.00 42.00 0.00 0.00 0.00 ---- 1.00 1.00 21.00 42.00 0• 00 0.00 0.00 ------0_00 TOTAL PERMIT 65.00 0.00 65.00 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT AMOUNT --------------- 65.00 --------------- 65.00 VOICE ID DESCRIPTION -------- ------------------ 106 SEWER & WATER REFERENCE NUMBER -------------------- visa VOICE ID DESCRIPTION -------- ------------------- 507 FINAL PLUMBING CITY OF CUPERTINO CITY OF CUPERTINO REPIPE/SEWS R/MAIN SERVICE PERMIT APPLICATION FORM .,nR ,---J2 APN # ,-56 Date- Building Address: Fee Group Uvey+;o Owner's Name: Phone #: Ala yl J Contractor: Phone #: �,5 '/ - (�, C.Q �0 GCT. Fax #: Phone #: 0gC� Conact: '5a6liG PdWe/a 1BPREPIPE Commercial r•; -pipe per fixture Fax #: Contractor License #: 750(ltl Cupertino Business License #: Z Z Commercial C'ras Piping System 1-4 Outlets Job Description:��j�/ VIP— Residential Commercial Residential ❑ Valuation: B ALL PERMIT TYPES Proj ct Size: Express Standard LJ Large Major LJ Seismic Commercial Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set S. the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial building sewer/sanitary. sewer P 1CPSS 1BPREPIPE Commercial r•; -pipe per fixture P 1CPRP 1PGASCOM Commercial C'ras Piping System 1-4 Outlets P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPEkTINO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type 1BCBSC Cal Bldg Standard Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building sewer/sanitary se vi er P 1RPSS 1 PRREPIPE Residential re -pipe: per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1 PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1 BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P I PGASRES Residential Gas R ping System 1-4 Outlets P 1 BPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit :gee Issuance P 1 PLMBLNCK Plumbing Plan Ct eck P 1PLMBINSP Other Plumbing/gas Insp. P j 1 1TRAVDOC Travel & Documentation Fee B 1 BUSLIC Business License B Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Build -,in Department JOB ADDRESS: PERMIT # i G ._� OWNER'S NAME: PHONE # Z5 (P GENERAL CONTRACTOR: FAX # II - I am not using any subcontractors: ' l� Si a DatV Please check a licable subcontractors ancora lete the following information: Owner/ Contractor Signature Date SUBCONTRACTOR BUSI-NESS 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