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12030006' - ' CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10315 ANN ARBOR AVE CONTRACTOR: BATH FITTER PERMIT NO: 12030006 NORTHERN CALIFORNIA OWNER'S NAME: STEVE ON(SHI 2118 ZANKER RD DATE LSSUED:03 /0220 1 2 OWNER'S PHONE: 4083688718 SAN JOSE, CA 95(33 PHONE NO: (408) 834-1111 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 CODIhIERCIAL 13 License Clacsd la,ic.4—/ �� S% / INSTALL NEW SHOWER/TUB VALVE IN 2 BATHROOMS C'ontmctor f --/Date 1 hereby allien (flat I am licensed under the provisions of Chapte�r9 (commencing with Section 7000) of Division 3 (if the Business & Professions Code and that my license is in full force and effect. hereby affirm under penalty (pf perjury one of the following two declarations: I have and will maintain a certificate ofconsent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: 54500 perti+mhmee of the work, for whichthis permit is issued. I have and will maintain Worker's Compensaimh Insurance, ms provided for by Section 3700 of the Labor Code, for the perfomtmtce of the work- for which permit is issued. APN Num her: 32655023.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read (Its application mid state that the above info. , run is PERMIT EXPIRES IF WORK IS NOT STARTED correct. ( agree to comply with all city and county ordinmices and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR W building construction, and hereby authorize represenmtives of (his city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY FRYM LAST CALLED INSP I C ION. indemnify and keep hamdess the City of Cupertino against liabilities,judgmenls, r costs, mild expenses which may accrue against said City in consequence of diee• L granting of this Permit. Additionally the giplicam understands and will canply Issued by: Date. Willi all non-poin our a egulmicns per the Culxnino Municipat Code, Section 9.18. RE -ROOFS: Signature Date All roofs shall be inspected prior to a y roofing material bene installed. If a roof is " - -rl installed withour first obtaining an inspection, I agree to remove all new materials for inspection. ❑ O\\'NER-BlI1LDER DECLARATION Signature of Applicant, Date: hereby affirm that 1 out exempir from the Contractor's License Law for (pile of Ute following two reasons: ALL ROOF COVERINGS TO BE CLASS' :A" OR BETTER 1, as owner of the property, or my enployees Willi wages as their sole compensation, will do the work. and the structure is not intended or offered for sok (Sec.7044, Business R PI'nfeS$l.a$ Code) I, us owner of the property, am exclusively contracting with licensed commetmrs to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read (Ire hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505. 25533, and 25534. 1 will hereby affirm under penalty of perjury one of the following Ilu•et' maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code. Section 25532(a) should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material Additionally, should 1 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 Itlanagennent District 1 perfonnmice of the wvd: for whichlhis permit is issued. will maintain compliance wish the Cpertmo Municipal Code, Chapter 9.12 and, I have and will maintain Worker's Compensation Insurance, as provided for by. the Health & Safety Code, Section.' _ ( _5533, acid 25534. Section 3700 of the Labor Code, for tie performance of the work for which this - Owner or authorized agent Date: permit is issued. I certify Uta in the performance of die work for Which this permit is issued,( shall not employ any person inmt• manner so as to becmcie subject to die Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to die Worker's Compensition provisions of the Labor Code, I must I hereby affirm film there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall to deemed revoked w'ork's for which this pemhit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read thisapplication mid sate dint the above information is coffee(. I agree to comply with all city and county ordinances mid state laws relating to building constriction, and hereby authorize representatives of this city to enter upon (lie above mentioned property for inspection purposes. (We) agree to save indemnity rand keep harmless the City of Cupertino against liabilities.judements. ARCHITECT'S DECLARATION costs, and expenses which may necme against said City in consequence of die . I unders(arhd my plans slhall be used as public records. granting of this permit. Additionally, the aggicant understands mid will comply Willi all non -point source mguhatiams per the Cupertino Municipal Code, Sectiah Licensed Professional 9.18. Signature. Date ' - ' CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10315 ANN ARBOR AVE CONTRACTOR: BATH FITTER PERMIT NO: 12030006 NORTHERN CALIFORNIA OWNER'S NAME: STEVE ON(SHI 2118 ZANKER RD DATE LSSUED:03 /0220 1 2 OWNER'S PHONE: 4083688718 SAN JOSE, CA 95(33 PHONE NO: (408) 834-1111 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 CODIhIERCIAL 13 License Clacsd la,ic.4—/ �� S% / INSTALL NEW SHOWER/TUB VALVE IN 2 BATHROOMS C'ontmctor f --/Date 1 hereby allien (flat I am licensed under the provisions of Chapte�r9 (commencing with Section 7000) of Division 3 (if the Business & Professions Code and that my license is in full force and effect. hereby affirm under penalty (pf perjury one of the following two declarations: I have and will maintain a certificate ofconsent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: 54500 perti+mhmee of the work, for whichthis permit is issued. I have and will maintain Worker's Compensaimh Insurance, ms provided for by Section 3700 of the Labor Code, for the perfomtmtce of the work- for which permit is issued. APN Num her: 32655023.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read (Its application mid state that the above info. , run is PERMIT EXPIRES IF WORK IS NOT STARTED correct. ( agree to comply with all city and county ordinmices and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR W building construction, and hereby authorize represenmtives of (his city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY FRYM LAST CALLED INSP I C ION. indemnify and keep hamdess the City of Cupertino against liabilities,judgmenls, r costs, mild expenses which may accrue against said City in consequence of diee• L granting of this Permit. Additionally the giplicam understands and will canply Issued by: Date. Willi all non-poin our a egulmicns per the Culxnino Municipat Code, Section 9.18. RE -ROOFS: Signature Date All roofs shall be inspected prior to a y roofing material bene installed. If a roof is " - -rl installed withour first obtaining an inspection, I agree to remove all new materials for inspection. ❑ O\\'NER-BlI1LDER DECLARATION Signature of Applicant, Date: hereby affirm that 1 out exempir from the Contractor's License Law for (pile of Ute following two reasons: ALL ROOF COVERINGS TO BE CLASS' :A" OR BETTER 1, as owner of the property, or my enployees Willi wages as their sole compensation, will do the work. and the structure is not intended or offered for sok (Sec.7044, Business R PI'nfeS$l.a$ Code) I, us owner of the property, am exclusively contracting with licensed commetmrs to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read (Ire hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505. 25533, and 25534. 1 will hereby affirm under penalty of perjury one of the following Ilu•et' maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code. Section 25532(a) should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material Additionally, should 1 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 Itlanagennent District 1 perfonnmice of the wvd: for whichlhis permit is issued. will maintain compliance wish the Cpertmo Municipal Code, Chapter 9.12 and, I have and will maintain Worker's Compensation Insurance, as provided for by. the Health & Safety Code, Section.' _ ( _5533, acid 25534. Section 3700 of the Labor Code, for tie performance of the work for which this - Owner or authorized agent Date: permit is issued. I certify Uta in the performance of die work for Which this permit is issued,( shall not employ any person inmt• manner so as to becmcie subject to die Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to die Worker's Compensition provisions of the Labor Code, I must I hereby affirm film there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall to deemed revoked w'ork's for which this pemhit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read thisapplication mid sate dint the above information is coffee(. I agree to comply with all city and county ordinances mid state laws relating to building constriction, and hereby authorize representatives of this city to enter upon (lie above mentioned property for inspection purposes. (We) agree to save indemnity rand keep harmless the City of Cupertino against liabilities.judements. ARCHITECT'S DECLARATION costs, and expenses which may necme against said City in consequence of die . I unders(arhd my plans slhall be used as public records. granting of this permit. Additionally, the aggicant understands mid will comply Willi all non -point source mguhatiams per the Cupertino Municipal Code, Sectiah Licensed Professional 9.18. Signature. Date 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32655023.00 DATE ISSUED.......: 03/02/2012 RECEIPT #.........: BS000016166 REFERENCE ID # ...: 12030006 SITE ADDRESS .....: 10315 ANN ARBOR AVE SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: STEVE ONISHI. ADDRESS ..........: 10315 ANN ARBOR AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: SylviaM COPY # : 1 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 148.50 --------------- 148.50 VOICE ID DESCRIPTION -------- ---------------------------- 10.6 SEWER & WATER REFERENCE NUMBER -------------------- visa VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 512 FINAL HANDI-CAP RECEIVED FROM ....: JOE NANNETTI CONTRACTOR .......: BATH FITTER NORTHERN CALIFORNI LIC # 31358 COMPANY ..........: BATH FITTER NORTHERN CALIFORNI ADDRESS ..........: 2118 ZANKER RD CITY/STATE/ZIP ...: SAN JOSE, CA 95133 - TELEPHONE ........: (408) 834-1111 FEE ID ---------- UNIT QUANTITY ------------- AMOUNT PD -TO -DT THIS REC NEW BAL -ADMIN ---------- HOURS 1.00 ---------- 41.00 ---------- 0.00 ---------- 41.00 ---------- 0.00 1BCBSC VALUATION 4,500.00 1.00 0.00 1.00 0.00 1BPFIXTURE NO OF FIXTURE 2.00 18.00 0.00 18.00 0.00 1BSEISMICR VALUATION 4,500.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 TOTAL PERMIT ---------- 148.50 ------ 0.00 ------- 148.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 148.50 --------------- 148.50 VOICE ID DESCRIPTION -------- ---------------------------- 10.6 SEWER & WATER REFERENCE NUMBER -------------------- visa VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 512 FINAL HANDI-CAP GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 I SC CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildina0cupertino.ora 1d030(X)L'*7 XMBING F1 MECHANICAL nELECTRICAL nUSrusCELLANEO V PLU PROJECT ADDRESS o. -r M APNa t3c2cP ss- oa 3 OWNERNAME P O�(1�1 EMAIL STREET ADDRESS 1 0%' CrrY $T TE, ffi D 09141 i/{,. FAX J�.t,� � � buil r PHO A E-MA CONTACT NAMIL E tor STREETADDRESS CRY. STATE ffi FAX ❑ OWNER ❑ OWNER -TRADER ❑ OWNERAGENT CONTRACIDR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DENTLU'ER ❑ TENANT, CONTRACT ( LICIN E NUMBER BE TY ^ IJ1 LQ BUS. COMPANY N /---1^7 ^� ( ! E-MAIL 1 1` ., j /J F // �jJ/L _i° e r 1. Mn . lix ARCHTTYCTIENGINEER NAME LICENSE NUNIBEi , BUS. LIC R COMPANY NAME E-MAIL FAX STREET AD°RFSS CIN, STATE, ffi PHONE USE OF ❑ STD m DIJ? E ❑ MULTI-FA,WLY BUILDING: ❑COMMERC PROJECT IN WGDLAND ❑ YES PRO= IN ❑ YES LIRBAN INTERFACE AREA ❑ NO FLOOD ZONE El No S THE BLDG AN ❑ YES MCHLER HOM ❑ NO DFSCRUMON OF WORK S � sh valy TOTAL VALUATION: Q RECEIVED BY: By my signature below, I certify to each of the f owin ,I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provid s have read the Desaipdon of Work and verify it is acntrat--. I agree to comply with all applicable loral ordinances and state laws rtlating to buildin on d rurntatives of Cupertino to =mr, the above -idea Sed perry for inspection pu(-poses. Signature ofApplicandAgent r � Date: Z. SUPP AL C7FORMATION REQ=D OFFICE USE ONLY y ❑ OVER-THE-COUNTER Y ❑ EXPRESS U U ❑ STANDARD Z 3 ❑ LARGE L ❑ MAJOR MEPMucApp_2011.doc revised 06121/11