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11010096 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21047 GARDENA DR CONTRACTOR: PERMIT NO: 11010096 OWNER'S NAME: JOHN JACOBS Lji_(h6 1�j(� C, DATE ISSUED:01/18/2011 t0"ITNER'S PHONE: 4082520556 , PHONE NO: G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class C 3,4CLie.# 379 3� / MECH RESIDENTIAL F COMMERCIAL r ContractorDate-V' X go, /OLrwM4C,4.F Date / � / I hereby affirm that I am licensed under the provisions/ JOB DESCRIPTION:REPAIR BLDG SEWER;ADD PROPERTY LINE CLEANOUT Chapter 9 (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: Val 0 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:32608084.00 A- e: 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 PEI WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WIT'WS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save 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 regulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. Signatu —� Date 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: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicaxit! 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 construct 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. 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's O ed agent: 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 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 's,and expenses which may accrue against said City in consequence of the ang 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 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21047 gardena dr. DATE: 01/18/2011 REVIEWED BY: bobs. APN: BP#: *VALUATION: 1$2,670 R*PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: p PERMIT TYPE: WORK re lace sewer line add property line clean out SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $21 TOTALS: $21.00 lfcc h, P(in Cho k Plumb.Plan Check 0.0 hrs $0.00 f, Ch"',k i-1�>c°`r. Pc>rrrt t F'ce: [Plumb.Permit Fee: IPPERMMT Oihcr,l/cc h, InsP, Other Plumb Insp. 0.0 hrs $42.00 01,, r 1;,`<c lty, 14t/�. It.Is. 1: .e. 1'.'tnuh. 1r:j;. Fcc: l fe hmp' 1-cc: NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-051 Ef. '.-%1:'10) FEE QTY/FEE MISC ITEMS Plan C'hecl,Fec: .`iupp/. PC'Fee F-1 PME Plan Check: $0.00 Permit 11e'e: .Sttpplt 111sp 1 C(2 PME Unit Fee: $21.00 PME Permit Fee: $42.00 ("'OnstnallOn Ttrr ,J('ouslic'ttl Reviel1: F(V. Work Without Permit? 0 Yes G No $0.00 1'lar71-1i1,.), 11ITS. Travel Documentation Fee: IT'RAVDOC $42.00 Stronk Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg;Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $106.50 $0.00 TOTAL FEE: $106.50 Revised: 01/03/2011 CITY OF CUPERTINO 5 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32608084 . 00 DATE ISSUED.. . . . . . : 01/18/2011 RECEIPT #. . . . . . . . . BS000012502 REFERENCE ID # . . . : 11010096 SITE ADDRESS 21047 GARDENA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : JOHN JACOBS ADDRESS . . . . . . . . . . : 21047 GARDENA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JAMES CACCIA PLUMBI CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL. ---------- ------------- ---------- ---------- ------ 1BCBSC VALUATION 2, 670 . 00 2 .00 0.00 2 . 00 0 .00 1BSEISMICR VALUATION 2, 670 . 00 1. 00 0 . 00 1.00 0 .00 1PPERMITFE FLAT RATE 1. 00 84 . 00 0 .00 84 . 00 0 .00 1PRSEWER UNITS 1. 00 42 .00 0 .00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 84 .00 0. 00 -----84_00 ------0_00 ---------- ---------- TOTAL PERMIT 213 .00 0 .00 213 . 00 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- ---------------------------- - 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 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: o?10 y 7 67"A A ao*-'-'& 1 PERMIT# j 00 OWNER'S NAME: -.7b.4</ .TA ccA S PHONE# So - 3 V2. -S3 get GENERAL CONTRACTOR:.T•VMEd' C74c4004 4L",. • BUSINESS LICENSE# ADDRESS:f/;" oV. I CITY/ZIPCODE: S,4•ci --tl A `o '9510 *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. / J/&/�/ I am not using any subcontractors: 5Z7:�577 Signature Date Please check applicable subcontractors and complete the following information: V 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 Ell CITY OF CUPERTINO GENERAL BUILDING CUPERTINO PERMIT APPLICATION FORM APN# kie Date: ` ' f Building Address• /? J n- 1o� 1 Gua br � - r{'1 wL Vtt Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes F1 No HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA If Residential, is house an Eichler? Yes ❑ No ❑ If yes, needs planning approval. Owner's Name: Phone#: Contractor: Phone: (,a,5b- 'L0- Fax: -Fax: Ka,S✓3Y� Contractor License Cupertino Business License#: Contact: RAOO� � Phone: la - �j Z•� Fax/e-mail: Residential Commercial El Job Description: i r f jlG�j �a�r A&o �- Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Type of Construction (Usage Class): Occupancy Typ� I-A, I-B ❑ II/III/V-A ❑ lI/III B, IV-HT, V-B S---' � Valuation: Square Footage: Project Size: Counter Q/Ex ress ❑ Standard ❑ Lar e ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.buildit reen.or Revised 12/06/10