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12010041 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10311 JOHNSON AVE CONTRACTOR:VIP PLUMBING AND PERMIT NO: 12010041 DRAIN CLEANING OWNER'S NAME: SANTOS FAMILY LLC 4020 PAYNE RD DATE ISSUED:01/05/2012 OWNER'S PHONE: 9253395747 PLEASANTON,CA 94588 PHONE NO:(408)644-2288 im LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class / Lic.# 'I 7 G �O V� ��,�J�r ; S 1.2MECH r RESIDENTIAL r COMMERCIAL Contractor (9- Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE SEWER LINE AT COMMERCIAL PROPERTY (commencing with Section 7000)of Division 3 of the Business&Professions LINE Code and that my license is in full force and effect. 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. 99 I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: luation:$2750 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION APN Number:37518034.003upancy 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 P IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, i 18 'DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the gQjDA`' S FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point so cc r ulaf s ver the4,Cupertino Municipal Code,Section ' 9.18. Issued b< Date•/ Signature Date ❑ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 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 I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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,I Own f autho (ze become subject to the Worker's Compensation provisions of the Labor Code,I must Date: S forthwith comply with such provisions or this permit shall be deemed revoked. ONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of Mrk's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37518034 . 00 DATE ISSUED. . . . . . . : 01/05/2012 RECEIPT #. . . . . . . . . : BS000015678 REFERENCE ID # . . . : 12010041 SITE ADDRESS . . . . . : 10311 JOHNSON AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : SANTOS FAMILY LLC ADDRESS . . . . . . . . . . : 10311 JOHNSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : VIP PLUMBING&DRAIN CONTRACTOR . . . . . . . : JAROSLAN SKOCZYLAS LIC # 30621 COMPANY . . . . . . . . . . : VIP PLUMBING AND DRAIN CLEANIN ADDRESS . . . . . . . . . . : 4020 PAYNE RD CITY/STATE/ZIP . . . : PLEASANTON, CA 94588 TELEPHONE . . . . . . . . : (408) 644-2288 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 2, 750 .00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 2, 750 .00 0.50 0. 00 0.50 0. 00 1PCSEWER UNITS 1 .00 22 . 00 0. 00 22 .00 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 152 .50 0. 00 152 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 152 .50 #2789 --------------- TOTAL RECEIPT 152 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 507 FINAL PLUMBING Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: A V^ PERMIT# l('�0 �''1 f OWNER'S NAME: h,; L LLC PHONE# 40 4 —,22 GENERAL CONTRACTOR: Ve 71 tfic BUSINESS LICENSE# ADDRESS: 60 /v" PP . CITY/ZIPCODE: N 1 i/ *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL S CO 5ACTO HAV TAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractor Signal ate Please check applicable subcontractors and com a 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 Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10311 johnson ave. DATE: 01/05/2012 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$2,750 r PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY Commercial Building PENTAMATION 1ePSS USE: --TPERMIT TYPE: WORK re lace sewer line at commercial property line. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PCSEWER 1 # $22 TOTALS: $22.00 77 Plumb.Plan Check 0.0 hrs $0.00 Ai,„ . Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $44.00Li NOTE: This estimate does not include fees due to other Departments('tie.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the relinina information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee Resolution 11-053 Bff 7-1./11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? Yes (j) No $0.00 Travel Documentation Fee: 1 TRA VDOC $44.00 Strong Motion Fee: 1BSEISMICO $0.58 Select an Administrative Item B1dyStds Commission Fee: IBCBSC $1.00 _SUBTOTALS: $152.58 $0.00 TOTAL FEE: $152.58 Revised: 1/01/2012 GENERAL PERMIT APPLICATION MEP ELI] COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408)777-3333• buildingQcupertino.org MISC ®PLUMBING ❑MECHANICAL/� ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS i�1 1i t(f ApN# 5-7 _ Y 025 OWNER NAME - 1`Q� ' �`/ PHO r E-MAIL 5147- STREET ADDRESS I • CITY, STAB STS U FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT JACCONTRA , N� { Tic �O T.ICE�LSE BUS.LIC# AN COMPY NAME I� E �uM MY I t Q7—.C C7 F 2 q-q —1 g J STREET ADDRESS `',, O•. J^ STALE ZIP i �S J PHSONE ARCHTTECTIENGINEER NAME LICENSE NUMBER o BUSS..LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK �— TOTAL VALUATION: �/` 2 RECEIVED BY: C By my signature below,I certify to each of the following: 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 provi d is orrect. 1 have read escription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ng c representati upertino to enter the above-i entified property for inspec on pu#poses. i Signature of Applicant/Agent: bate; .5 �o� SUPPLEMENTAL INFO , ON REQUIRED OFFICE USE ONLY y� OVER-T'HE-COUNTER Y ❑ EXPRESS U W ❑ STANDARD S U ❑ LARGE a ❑ MAJOR MHPMiscApp 2011.doc revised 06121111