09100196 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11406 LINDY PL CONTRACTOR:DEMPSTER PLUMBING PERMIT NO:09100196
OWNER'S NAME: BERNEDETTE&KELLY HIRANO 1639 POMONA AVE DATE ISSUED: 10/28/2009
IER'S PHONE: 6505802904 SAN JOSE,CA 95110 PHONE NO:(408)295-3911
LICENSED CONTRACTOR'S DECLARATIONI I�
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class
# MECH I RESIDENTIAL I COMMERCIAL I
Contractor ` Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPIPE IN COPPER FROM METER TO ALL
(commencing with Section 7000)of Division 3 of the Business&Professions FIXTURES
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:$11000
I 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:35624011.00 Occupancy Type:
APPLICANT CERTIFICATION
1 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 source regu {der the Cupertino Municipal Code,Section Issued by � Date:
9.18. / )
Signature Date
RE-ROOFS:
LJ 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
1 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)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
constrict the project(Sec.7044,Business&Professions Code).
I 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. I 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 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's Owner !�\ Date: �b /� ✓G i'
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constriction 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
inify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply 1 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
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35624011. 00
DATE ISSUED. . . . . . . : 10/28/2009
RECEIPT #. . . . . . . . . : BS000009061
REFERENCE ID # . . . : 09100196
SITE ADDRESS . . . . . : 11406 LINDY PL
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : BERNEDETTE & KELLY HIRANO
ADDRESS . . . . . . . . . . : 11406 LINDY PL
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4814
RECEIVED FROM . . . . : WILLIAM D DEMPSTER
CONTRACTOR . . . . . . . : WILLIAM DEMPSTER LIC # 31263
COMPANY . . . . . . . . . . : DEMPSTER PLUMBING
ADDRESS . . . . . . . . . . : 1639 POMONA AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95110
TELEPHONE . . . . . . . . : (408) 295-3911
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 11, 000 . 00 1. 00 0. 00 1. 00 0 .00
1BPFIXTURE NO OF FIXTURE 3 .00 24 . 00 0 . 00 24 . 00 0 . 00
1BPWATER UNIT 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
1BPWSVCS WATER SERVICE 1 . 00 21 . 00 0 . 00 21. 00 0 .00
1BSEISMICR VALUATION 11, 000. 00 1 . 10 0 . 00 1.10 0 . 00
1PPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 42 .00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 173 .10 0 . 00 173 . 10 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 173 .10 VISA
---------------
TOTAL RECEIPT 173 .10
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 301 ROUGH PLUMBING
507 FINAL PLUMBING
CITY OF CUPERTINO vim/ /o
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN #� � ,, Date: j
Building Address: /q/4/
Owner's Name: r ,� �/��. �U Phone#: %� 7
�S C. -5', G am% f G�
Contractor: / Phone#: t/4)g' z`i S- -37 /1
.�e' v� 5� �„ ►=� �� v`c Fax#:
Contact: �� t, ` . F,;— Phone#: YG S'
Fax #:
Contractor License#:
Cupertino Business License#: ? '�
Job Description:
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
1 PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
aE-- REPIPE/SEWERIMAIN SERVICE
Of
CUPER,TINO FEE SCHEDULE
Quantity Fee ID Fee Description „ Fee Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1R-PSS
sewer/sanitary sewer
1 PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
f 1PPERMITFEE Plumbing Permit Fee Issuance P
/ 1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
/ 1 TRAVDOC Travel & Documentation Fee B
1 BUSLIC Business License B
M.Indoor Air Quality and Finishes
1.1feL.b*WVOC P IM 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use LD►voAd 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
41AQ/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 IA0/1-lealth pts y=yes 0
1 1 1
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
1 1 1
Total Points Available: 1 1401 1301 57
Total Points Pro'ect Received: l �� 0 0 0
G:data/progs/greenbuilcOngguidelines/remodelers/greenpointsfinal2.12.D4protected.xls
Community Development
10300 Torre Avenue
i- Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
,MkTINO
-Building Department
JOB ADDRESS: 11411-)4 PERMIT # Q
OWNER'S NAME: PHONE # 63
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
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
e'
Owner/Contractor Signature Date