08110008 CITY OF CUPERTI `M'Mf';;^
BUILDING.DIVISION PERMIT CONTRb(CT k4NFlZMA�T'` 'TO
i
BUILDING ADDRESS: PERMIT NO.
21094 REQ FIR CT TO RE DFTFRMTMT7l1 nPI q ()nng
OWNER'S NAME: PERM"ISSUE DATE
A CONTROL NO.
ARCH1ECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION
u I nembY alarm that l ren lir<n w under pmsdsom Of Chaper 9(mmmmcing Job Description
W viN Secdan]OfNI)of DiHsion3ef0e Busircuand Pra(udam Cade,and myliccnscu
n y in full force COPPER RE—PIPE
j ya z License Clue Lic.0 Z Z ,
M;:, Dau: Conuacnr t
wwwy ARCHITECTS DECLARNUON
< 1 uncerwnd my plans Gull he used as public mcmda
6
b 0 N Licensed PNICStio al
OWNER-BUILDER DECLARATION
I Wreby ef<m in.,1 em exempt fmm tW Contractors License Law for that
i oo following mason.(Section 7031.5,Bvdoass and Pmfedons Code:Any city or county
_ which acquire,a pmmit in coma on.-her.impmw.demolish,or repair any structure
prfarmiu iuumee.also requires daapplicant forsuch pcmitm rik-sigmesutemem
ppssi that he is licensed pursuant in the provisions of the Conturacra's Liecruic Law(Chapter 9 Sq.Ft.Floor Area Valuation
yF� (commencing with Section 7000)of Divialon 3 of the Business and Profassioau Code)of
— that he is aattempt Aeafrom and the b•^•for fla alleged eaempdm.Any violation of $3484
Section 7031.5 by any applicator for a permit mbjecu cite applicant to a dvil penalty a APN Number Occupancy Type
not mom Nen fiw hundred dollars($.100).
❑I.as awmr of the property.or my employees ww wages,u mein role cmnpemwon, 35905047 . 00
win do the woh.and the structure is amt intended or oReed for tale(Sec.7044.Busimas Required Inspections
Ad Pmlo
fassns Code:The Commutes Comuses Liana m e ns law does not apply an owner or 9 P
property who build,o im proves miction,and who does such work himsel f or through nu
own emplo5sa,provided that inch impmsumenu art not intended ooffemd fossa B, -
howe..Ne building or impmvement useld within om Sete of completion.the awm a-
builder will naw the burden of proving that k did nal Wild or improve for pu Pom of
uk.).
(]1,is owner of the property.w mckuwly canusning with licensed conuxbrs to
construct the project(Sec.7044.Business and Plokaalons Code:)TIC Contractors IJ-
cense law docs out apply an an owner of prepcny who Wilds or lmpmwa thereon,and,
who cmtracu for such p cjems with a contractor(s)licensed pursuant In flue ConuscsnYs
Liana law.
❑I sal attempt under See ,B h P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
1 barony affirm under may of perjury one of the following declensions:
l las.and will..law.•Cmifimu ofCouenl is alf-insure fm Wartrr's Comprn-
'm.as provided for by Section 37M of the Labor Code.fed An perfmmanxt of fly
work for which this permit is issued.
❑I bow and will maintain Workafs Compensation Insurance,u required by Section
37M of the labor Codc,for the performance of the work forwhich{bit permit u issued.
My Wokera Cammpeuauan l Tana artier and PWiry n'uader>R:
Cartier.,;d1� Policy No.:,�/j�o/9Oy9SI
CERI IFICATE OF EKEMPITON FROM WORKERS
COMPENSATION INSURANCE
fruit sec0m seed ms becompleted if the pemit Is free=hundred dollars(8100)
lir lata)
L artily that in the performance of the work far which this Permit is issued.I shell not
employ any person in any manner so as to become subject to the Workcn'Compmutioo
Laws of Calif rmia.Data
Applicant
NOnCE TO APPLICANT:IL after mAing tris Certificate of Exemption.You Amid
become subject to the Workers Compensation pm,Wons of Ne La Wd Code.you a.
.J O forthwith comply with such provisions m this permit shall W deemed meted.
Z 51 CONSTRUCTION LENDING AGENCY
.F.+ Ihemb,aRnn that them k a mautmcfrm lending agency for tW Nofomance of
the work for which this permit Is issued(Sec.3077,Civ.Q
Q lander,Name
z LeZue.Add.
U O 1 cor ify that 1 have road this application and Aute the doe mow iarmawdun B
E manses.I agree b comply with all city and county ornimer,..and sun Int raboing to
.O Wilding consuuctfan,and hereby authadn uoaamtal, a of this city to enet.,xn the
R7 aWve-mentioned pmpeny for inspection purposes.
�'gy (We)agree to saw,Indemnify and keep hamlet{the City of Cupertino against
y Tiabilitimjudgmcnu.cusuaadexpemesw ich may NanY w'aY acme a8almrtmdChy
U z mcaurqummofthegrantingofthispe it.
APPLICANT UNDER ST DS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATIONS
Re-roofs
Sig or or ApplicamlCon ^ Date
xAZARD Alt Dlsao E Type of Roof
Wilby t ep .Pers m fu l Co ettupantswn or auntie Heznt aid Safety u Med by the Cupeniw Munici I Code.CMpter 9.12,and the Fkilth and Safety
Cale.Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Yes d o
wn the applicant or future Wilding occupant use,Nulpmmt or device.{which If a roof is installed without first obtaining an inspection,I agree to remove
nit har7 ardnus air conuminanu u fired ocd by the Bay AAir Quality ManagcmcnL all new materials for inspection.
suia /Sk
Dye [}Nu
1 have read the huaNnus maunalsmquimmmu under Chaper6.95 ortheCalifor-
m.Naw&sefetycodas«fions755D5. 533am121534.1ouCrsuMthnifdc Wilding
dna rot wy n.w y this n my myaaminiufy m noairy the ceenp,nt lir nae
requirelush Gs {(mor i,tuanaaaacenirte.eoraaup-amt. Signature of Applicant Date
r or authamed a gent Date- All roof coverings to be Class'n"or better
CITY OF CUPERTINO
• 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . .. 35905047 . 00
DATE ISSUED. . . . . . . : 11/03/2008
RECEIPT # . . . . . . . . . : BS000006530
REFERENCE ID # . . . : 08110008
SITE ADDRESS . . . . . : 21094 RED FIR CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : ANNE SOMMERVILLE
ADDRESS . . . . . . . . . . : 21094 RED FIR CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JA PLUMBING
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 .
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-------- ---------- ------- ------- --- ---------
1BPWATER UNIT 1 . 00 40 .79 0 . 00 40 .79 0 . 00
1BPWSVCS WATER SERVICE 1 . 00 20 .40 0 . 00 20 .40 0 . 00
1BSEISMICR VALUATION 3 , 484 . 00 0. 50 0 . 00 0 . 50 0 . 00
1BUSLIC FLAT RATE 1 . 00 110 . 00 0 . 00 110 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---- ---------- ----------
TOTAL PERMIT 253 . 27 0 . 00 253 . 27 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------- ----
CHECK 253 . 27 #3522
---------------
TOTAL RECEIPT 253 . 27
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- --- ---- --- ----------- -------
106 SEWER & WATER 301 ROUGH PLUMBING
507 FINAL PLUMBING
0O-eA At Cvwti [t
-� CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
• CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
26 q� 50 Lf 7 ,
Building Address:
, T
Owne 's Name: Phone#: e,31
Contractor: // Phone#:(;/07
Fax #:
Contact: Phone #:
Fax #:
Contractor License#:
Cupertino Business License#:
Job Description: ecpi4-A� X jYJe
Residential X Commercial ❑
Valuation:
Project Size: Express ❑ Standard�]C 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
IPGASCOM Commercial Gas Piping System P
1-4 Outlets
IBSEISMICOM Seismic Commercial P
/ 1BSEISMICR Seismic Residential P
1PRSEWER Residential building P IRPSS
sewer/sanitary sewer
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CITY OF
CUPEkTINO FEE SCHEDULE •
Quantity Fee ID Fee Description Fee Permit Type
Group
1PRREPIPE Residential re-pipe per fixture P 1RP-RP
I 1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
/ 1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
/ 1PPERMITFEE Plumbing Permit Fee Issuance P
IPLMBLNCK Plumbing Plan Check P •
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel &Documentation Fee B
1BUSLIC Business License B
Revised 6-16-08