09010088 CITY OF CUPERTINO
BUILDING DIVISION PERT
BUILDING ADDRESS: PERMIT NO.
21612 REGNART RD PRO ROOTER
OWNER'S NAME: PERMIT ISSUE DATE
A CONTROL NO.
510) 670-1115
ABUILDING PERMIT INFO
RCHIfECl/ENGINEER:
B� ELECTO PLUMB�
u p C LICENSED CONTRACTOR'S DECLARATION Job Description
Curi I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code.and my license is
y in full fora and affect. t ` REPLCMNT OF APPRX 50 FT OF 4INCH MN SWR FRM HME
j License Cf Lle.8 6 6�S
F Date a Contractor v a OUTLT TO 134 CLEANOUT ACCESS
ARCHITECTS DECLARA71ON
tt l understand my plans shall be used as public records
D U
L 0 in Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Ltccnse Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y:3� which requires a permit to construct,alter,improve,demolish,or repair any structure
EO prior to its issuance,also requires the applicant for such permit to file a signed statement
cthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
vt—$ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
a that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(s500). 35623003 . 00
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of �l P
property who builds or improves thereon,and who does such work.himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
e
C11,as owner of the property,am exclusively contracting with licensed contractors to n �
construct the project(Sec.7044,Business and Professions Code:)ThContractor's Li
cense Law does not apply to an owner of property who builds or improves thereon,and, sfi 4 t
who contracts for such projects with a contractor(s)licensed pursuant to the contractors A a License LAW. LiI
❑II am exempt under Sec .B R P C for this reason
Owe Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
.ton,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance amen number are:
Came>:(s7?r? car,D�sra�l 219 k ii5 4
CERTIFICATE OF EXEMPTION FROM WORKERS' clf�vo
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is for one hundred dollars($100)
or less)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
[~•n r�r I hereby affirm that there is a construction lending agency for the performance of
lY,hrte work for which this permit is issued(Sec.3097,Civ.C.)
W 0 Lenders Name
�
Z
Lcnders Address
U O 1 certify that I have read this application and state that the above information is
LL h ' comet.l agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
0. (We)agree to save,indemnify and keep harmless the City of Cupertino against
o.4 y liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR REGU TION
cel• r °/ Re-roofs —
Signature&Appliant/Conuwtor 'te Type of Roof
HAZARDOUS MATERIALS DISCLOSURE/
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya 0 No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.strict?
❑Yes No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k SafetyCode,Sections 25505,25533 and 25534.1 understand that if Ute building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requircmcns which must met pria toissuance era certificate of Occu Signature of Applicant Date
a ° a. All roof coverings to be Class" ``or better
Owner aut zcd agent Da
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . . 35623003 . 00
DATE ISSUED. . . . . . . : 01/20/2009
RECEIPT #. . . . . . . . . : BS000007004
REFERENCE ID # . . . 09010088
SITE ADDRESS . . . . . : 21612 REGNART RD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER WOLIN DAVID AND BETTY TRUSTEE
ADDRESS . . . . . . . . . . : 21612 REGNART
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4821
RECEIVED FROM . . . . : LESBIA MASON
CONTRACTOR . . . . . . . : JIN OH DBA PRO ROOTER INC LIC # 24097
COMPANY . . . . . . . . . . : PRO ROOTER
ADDRESS . . . . . . . . . . : 2306 AMERICA AVE STE 7
CITY/STATE/ZIP . . . : HAYWARD, CA 94541
TELEPHONE . . . . . . . . : (510) 670-1115
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 4, 800 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 4, 800 . 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 103 .48 0 . 00 103 .48 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 103 .48 AMEX
---------------
TOTAL RECEIPT 103 .48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # C U Date: 0/ v� �
Building Address: / n WN T NT
Owner's Name: Phoneo� � _ 7�
vA e w o k V j az 7a�z
Contractor: Phone#: 5-, 6 76, -)115-
F ax
li/s"Fax #: S
Contact: Phone#:
y
Fax#:
Contractor License#: 6 G s-
Cupertino Business License#:
Job Description: �M � G'�
/ t jN �:e ' 'e FW'01y I-P r
Residential Commercial ❑
Valuation:
Project Size: Expres 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
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1 BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CITY F
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1 BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
1 PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1 PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1 BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas Piping System P
1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
/ 1 PPERMITFEE Plumbing Permit Fee Issuance P
/ 1 PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
/ 1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
M.Indoor Air Quality and Finishes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
! ! !
Total Points Available: 1 1401 1301 57
Total Points Project Received:1 1 01 01 0
G:data/progs/greenbuildinoguidelineshemodelers/greenpointsfina12.12.D4protected.xls
Community Development
10300 Torre Avenue
7 k0714
a
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: r,4V (IW;U) PHONE # L5-
GENERAL CONTRACTOR: ro 16aj,X1e "NC. FAX #
I am not using any subcontractors:
�app ()IL201" �
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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date