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10020011 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20102 RODRIGUES AVE CONTRACTOR:MOOMAN PLUMING PERMIT NO: 10020011 OWNER'S NAME: MARIE GATTO MICHELIS FAM LTD PTR 7094 INDIAN WELLS CT DATE ISSUED:02/01/2010 NER'S PHONE: 4085646599 SAN JOSE,CA 95139 PHONE NO:(408)788-8141 ❑ LICENSED CONTRACTOR'S DECLARATION r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL GASLINE FOR NEW GAS RANGE,FIELD (commencing with Section 7000)of Division 3 of the Business&Professions INSPECTOR Code and that my license is in full force and effect. TO VERIFY IF ISOMETIC DRAWING IS REQUIRED 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 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$700 permit is issued. APPLICANT CERTIFICATION APN Number:36932038.20102 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 relating 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. Issued Date: Signature Date L.i OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of 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 compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,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 Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. 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 shall 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,I become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorize nt: Date: forthwith comply with such provisions or this permit shall be deemed revoked. (J 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 -unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address .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,Section 9.1 g, I understand my plans shall be used as public records. Signat41, (�1 ' C � Date �/� �0 Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36932038.20102 DATE ISSUED. . . . . . . : 02/01/2010 RECEIPT #. . . . . . . . . BS000009663 REFERENCE ID # . . . : 10020011 SITE ADDRESS . . . . . : 20102 RODRIGUES AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MARIE GATTO MICHELIS FAM LTD P ADDRESS 20102 RODRIGUES AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MICHELIS FAM LMTD P CONTRACTOR . . . . . . . : U7PAL MEHTA LIC # 20881 COMPANY . . . . . . . . . . : MCOMAN PLUMING ADDRESS 7C94 INDIAN WELLS CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95139 TELEPHONE . . . . . . . . : (408) 788-8141 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- - --------- ---------- ---------- ---------- 1BCBSC VALUATION 700 . 00 1. 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 700 .00 0. 50 0 .00 0 .50 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 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 - - --------- ---------- ---------- ---------- TOTAL PERMIT 148 .50 0 .00 148 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 148 .50 #1010 --------------- TOTAL RECEIPT 148 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING CITY OF CUPERTINO REPIPE/SEWS R/MAIN SERVICE CUPE�TINO PERMIT APPLICATION FORM A P N# -3 �, 9— 3 —v 3 �, Date: Building Address- 910 /U2 91) do zo� e- Owner's Name: Ph ne Contractor: // Phone#: Pcyv r) c t vnh %° ✓1 Fax #: 4 4 3-51&- 3��� Contact: A Phone#: Fax#: Contractor License#: U 74-9 e2, Cupertino Business License#: Job Description: --0e) 0 ►�,� ��s � , ILI r© Residential Commercial ❑ ValuatioJy: Project Size: Express Er Standar 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 11CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Geis 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/SEWEFJMAIN SERVICE CUPE�TiNO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES r 1BSEISMICR Seismic Residential P I 1PRSEWER Residential buildi Zg P 1RPSS sewer/sanitary seNver 1PRREPIPE Residential re-pips per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1 PGASRES Residential Gas P.ping System P 1-4 Outlets 1BPGAS Gas Piping Syster.i 5+ Outlets P / 1 PPERMITFEE Plumbing Permit';ee Issuance P f . 1PLMBLNCK Plumbing Plan C1-eck P 1PLMBINSP Other Plumbing/gis Insp. P / 1TRAVDOC Travel & Documentation Fee B 1 BUSLIC Business License B Community Development is 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 :UPEI�TINO Building Department JOB ADDRES : PERMIT # OWNER'S NAME: M. �!h'-I/ PHO # S (oS GENERAL CONTRACTOR: GM FAX # I am not using any subcontractors: Si;nature Date Please check apphcable 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