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12010062 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21888 GARDENVIEW LN CONTRACTOR:ABLE SEPTIC PERMIT NO: 12010062 OWNER'S NAME: RICHARD SU P O BOX 24819 DATE ISSUED:01/09/2012 OWNER'S PHONE: 4082558988 SAN JOSE,CA 95154 PHONE NO:(408)377-9990 0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG 1— ELECT F PLUMB F License Class c-4,P Lic.# MECH F RESIDENTIAL COMMERCIAL � Contractor DateZ-- I hereby affirm that I am licens d under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL PROPERTY LINE CLEAN-OUT (commencing with Section 7000)of Division 3 of the Business&Professions 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. Sq.Ft Floor Area: Valuation:$2500 1 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 permit is issued. APN Number:32619093.21888 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point sour regulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. Signature Date4l 12- RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). 1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the p Health&Safety Code,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker'sHt�- gent• Compensation laws of California. If,after making this certificate of exemption,I Date: become subject to the Worker's Compensation provisions of the Labor Code,I must kc.14--r 4* forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date 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: $ >r PERMIT# OWNER'S NAME: - %/j — PHONE# *j — GENERAL CONTRACTOR: ` BUSINESS LICENSE# ADDRESS: y- CITY/ZIPCODE: Q *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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: y42;�-- I � i2 70 Signature Date Please check applicable 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 Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32619093 .21888 DATE ISSUED. . . . . . . : 01/09/2012 RECEIPT #. . . . . . . . . : BS000015706 REFERENCE ID # . . . : 12010062 SITE ADDRESS . . . . . : 21888 GARDENVIEW LN SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . RICHARD SU ADDRESS . . . . . . . . . . : 21888 GARDENVIEW CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1132 RECEIVED FROM . . . . : ABLE CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407 COMPANY . . . . . . . . . . : ABLE SEPTIC ADDRESS . . . . . . . . . . : P O BOX 24819 CITY/STATE/ZIP . . . : SAN JOSE, CA 95154 TELEPHONE . . . . . . . . : (408) 377-9990 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, 500 .00 1. 00 0 . 00 1.00 0. 00 1BSEISMICR VALUATION 2, 500 .00 0 .50 0. 00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 44 .00 0. 00 44 . 00 0 .00 1PRSEWER UNITS 1.00 22 . 00 0. 00 22 . 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 18415 --------------- TOTAL RECEIPT 152 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING � CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21888 garden view In. DATE: 01/09/2012 REVIEWED BY: bobs. APN: U Y� BP#: "VALUATION: $2,500 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex lex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $22 TOTALS: F $22.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs 1 $44.00 NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These.fees are based on the prelindina information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (Fee Reso%rtion 11-053 Etf ''1;`'11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 7-1 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? 0 Yes (E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 StI•ona Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldp-Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $152.50 $0.00 TOTAL FEE: $152.50 Revised: 1/01/2012 �X� GENERAL PERMIT APPLICATION 00 M E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 1 MISC CUPERTINO (408)777-3228• FAX(408)777-3333•building a().cupertino.orp \` PLUMBING MECHANICAL FlELECTRICAL MISCELLANEOUS S646 PROJECT ADDRESS APN# 13Z& ^ ..D q ,4 OWNER NAMET,; / ' ) -rrj Ck*% P E-M.IL ^ ' JJ , 7 1 6:1 `QI � • - STREET ADDRESS �• FAX Item 2-1 ng 0 CONTACT NA • V t ltril�` �Qlf+/` V STREET ADDr STATE, sSS? C 1P FAX OWNER 0 OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTR R AME / • LIC S914113 LIC)j E BUS.LIC tk COMPAtNj'N,W E STREET DD�F�S^ 44 1pe. CIT A 1P �� HO ��i 71-1110 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME • E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? U)NO DESCRIPTION OF WORK ITOZE=LIM CAMd&j 'Ojai OPOP TOTAL VALUATION: RECEIVED BY: 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 ct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating/ on. I authorize representatives of Cupertino to enter the abov Iden ified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLE TAL INFORMATION REQUIRED OFFICE USE ONLY w ❑ OVER-THE-COUNTER ❑ EXPRESS y ❑ STANDARD U a ❑ LARGE a ❑ MAJOR MEPMiscApp_M I.doc revised 06/21/11