08120041 CITY OF CUPERTINO �
BUILDING DIVISION PERA41T i�IEl,fu's\+TQIA� •`^� �� �',Mi
BUILDING ADDRESS: PERMIT NO.
1053 COLONY HILLS LN ECONOMY PLUMBING
OWNER'S NAME: PERMIT ISSUE DATE
gNE: AR151 14TDICKX-RY R9 a CONTROL NO.
jos 2_69_C,/_ (650) 697-5100
ARCHfTE INEER.. 1 BUILDING PERMIT INFO
�(-�MD Idzs�� BLDGO ELECT CS PLUMB MECH
O O
iso Zp LICENSED CO ACTOR'S DECLARA lob DeSCTIpu00
it a�C I Eaeby arfinn dist 1 am 1' undo proritioru of par 9(mmmeneing
e t� with Sce--... XI)afDivialon3ofdu 8usinuv and Pro(cs®am ode,and myliccnc is
inollfomeandpfteat�/'� PROPTY LINE CLEAN—OUT FOR ACCESS TO SEWER
ense�yy n r Lte.a y �r�g5
n h Date CDaI�_1 -
e Q4 ARCHITECTS ECLARATION
1 understand my plans shat the used as public records
DyU
g o Licerued Pmfrssianal
OWNER-BUILDER DECLARATION
too1 Mrchy nlErm that I am exempt Business an Ntr Contractor&License Law co Ne
i O O following mama.($aeon IID lq , Ich. and Pofuanns Code:Any city m county
$w which road.
its W •Pearn re construct,the alma impaw,demur W, fl c a sig my stoctum
i� poor oiuiacwmmursu requires toue Novisios,of
Conlarach rmitoice asiged&umnent
p�p Nat he is licensed pursuanu.tits previsions of Ne Conumor's Liansclaw(G.per9 \ Sq.Ft. Floor Area Valuation
y (commcndngwiNScction70DO)or Division3afdm Rusim mdPolaswn'Ca, )or 1
$
that he u attempt Ncmfom and the basis fm the alleged csemptlan.Any violation of 2 5 0
Section 70113 by say applicant fm a Peonit subjcm to applicant to a mutt recall of APN Number Occupancy Type
an,ream dell rive hundred dollars MOZ. 35930005 . 00
❑1,u owner of Ne PmPemy,a mY employe with wags as Nelr sole comPensadon,
will dodmsions CWdu he Co tusms I lesson LawrW farsa apply 7U44,Bnto Of Required Inspections
and property
who ns Cadc The m decors nd who law dohs Out apply if an o ugh is q P
own
wit.Wilds ri i d Oar such im rommeha am n smhwpk himselfed though his
oww,,,,, nWildiogorhaptsuch iso,,olmenuanemt inundcompleerea foe anent '
however,iR an Wilding m Imporemmt Is sold within ne yea of completion,the awes-
buiMer wiB haw Ne buNa of poling Nat he did an,MtiW Or improve for purpose of
saloe.1-ro ower of ct Pmpny,.B sine s.4 concocting with Ilansea coaateme. . TARY
mm,as the profess(See.property,
col�ssi and contracting Cade:)The Conuacors to
ansa law does not reach
r e an ower of patens who Nods m imprmwa Neem.and, zoAN
who contnm far omit pmjecu with a conv.ctor(s)lianscd pursuant o Ne GnvetorsLicense Law.
C lam aempt macer Sec ,B&PCfar Nis rtas.n
Ower Daus—
WORKER'S
auWORKERS COMPENSATION DECLARATION
PI hereby air=under pevalty of perjury arc of On fallowing declaePaorne:
I hum am will maintain•Certifmau ofcoment to self-tours fm Wmkers Comper,
aan,as provided fu by Sada.11110 of the labor Code.fm On perform.of do
wart for which Nis Permit is issued. .
C I have and will maintain Workers Compensation Iasoance,a required by Section
3700.17 On Labor Code.for the,pufmccoace of the work far which Nig Permit is iced.
are:My WmkaesCn pemadon bra ma carrier and Policy nmer
Grrier. Policy No.:fT ! IFROM
TE
COMPENSATIONINSURANCE
S
,-I
Cnissectlm sued not be compleod if the Permit]&foram hundred dollars($I00)
or lnsa)
I ratify Nat in the Mr... far which this permit u immed.I ahall not
employ any person in any r to become subject to On Wadori Compemadan
Law,n of Cali( D
Applicant
NOTICE TO APP CANT:IL after making this Ceniriata of Exemption,you shmhl
become suhim to the Worker's Compensation porisions of the labm Code,you masa
�z forthwith comply with asset Povisiono or Nu permit shall be deemed armlad.
z 0 CONSTRUCTION LENDING AGENCY
1 hereby affum door then is.construction leasing.genu,far the Perrionsuc.f
On work for whim Nig Permit u iasuW(Sec.3097.Civ.C.)
aLenders we
7 z Landers Address
U Q 1 century Nat I have rad this applicaion W sum Nu the&bore infam us.u
U. cannot,I agree o comply with al city and county ordinmwws es orb sum lamisting o
.C) C) building construction.and hereby auNadw rtpmsan=iw of Nis city to enter upon the
above-mentioned property for inspetian purpoxa
(We)&gra to saw,indemnify and kap harmless Ne CITY of Cupenirm against
f0.j1 liabilities.)udgmenu.costa and eaPemu which may I.say,way amus against said City C,g
U z in consomme of the granting of this parmiL
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE REGULATIONS
Sitnuum of A�`p Xontracor 1 Data
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will use appliant ser forum bWlding aavpntaom m hWk hrurdoas material
as deBmd by the Cupertino Municipal Code,Chapter 9.13.W Pate Health and Safety
Conn.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
CYu
will Pate applicantser comm Wilding aavpa.t use equipment or a.I.which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as dcBncd by the Bay Area Nr Quality Management all new materials for inspection.
o aT
❑Ya
I hew real the ha material rtquimmenu under ClupterG95ofNeCaifm-
m.HulN&SaelYCOIa'Satbns 505,25533 and 25534.I undersand thetifdte building
Jou et currently h.a NCht 4 my responsibility to ratify the oceupent or On
mqurcrmnawhich mclpdaroaa..f.Ccrih:atea Signature of Applicant Date
owner.r.a .Para again /e Do All roof coverings to be Class'W'or better
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35930005 . 00
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT #. . . . . . . . . : BS000006750
REFERENCE ID # . . . : 08120041
SITE ADDRESS . . . . . : 1053 COLONY HILLS LN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JOE & RUTH STEVENS
ADDRESS . . . . . . . . . . : 1053 COLONY HILLS LN
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5801
RECEIVED FROM . . . . : VICTOR MARTINEZ
CONTRACTOR . . . . . . . : DAN GRIFFIN LIC # 29238
COMPANY . . . . . . . . . . : ECONOMY PLUMBING
ADDRESS . . . . . . . . . . : 861 HINCKLEY RD
CITY/STATE/ZIP . . . : B'URLINGAME, CA 94010
TELEPHONE . . . . . . . . : (650) 697-5100
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 2 , 050 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRSEWER UNITS 1 . 00 20 .40 0 . 00 20 .40 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
TOTAL PERMIT 102 . 48 0 . 00 102 . 48 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
---------------- -------- ------------------
CASH 102 . 48
---------------
TOTAL RECEIPT 102 . 48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
•
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CITY OF CUPERTINO
Q' REPIPE/SEWER/MAIN SERVICE
CUPEI�TINO PERMIT APPILICATION FORM
APN # Date:
3�5q a.o ,005 , oo
Building Address:
053 C'
Owner's Name:. Phone #:
/L Skv s 466 fk$- 136 -7-
Contractor: Phone#:
.tr-60�/o7 f�G�u2r b�iu� -14 2(,$ 9650
\/ Fax #:
Contact: Phone #:
Fax #:
Contractor License #: 7 D
Cupertino Business License #:
Job Description: ro��C��cL Ge&c/—
(' or 5L_e-ceSS
Residential Commercial ❑
Valuation:
Project Size: Express ❑ 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
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
' 1BSEISMICR Seismic Residential P
I 1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkT`iNO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
iPRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
IPCESS Cesspool P
1BPWATER Install/alter Water Pipe P
IBPFIXTURE 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
I
1PLMBLNCK Plumbing Plan Check P •
1PLMBINSP Other Plumbing/gas Insp. P
ITRAVDOC Travel & Documentation Fee B
IBUSLIC Business License B
Revised 6-16-08
•