10050174 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10534 N BLANEY AVE CONTRACTOR:GREENFIELD PLUMBING PERMIT NO: 10050174
OWNER'S NAME: CHANG TRUSTEE 35 3 MADRID DR DATE ISSUED:05/24/2010
WNER'S PHONE: 4088288688 SAV JOSE,CA 95132 PHONE NO:(408)921-8980
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
icense Class 6 Lic.417 J Z"" REPIPE FROM METERE TO THRU OUT HOUSE
Contractor l(Z i / P,zy['}; Date —Z — ( 0
I hereby affirm that I am licensed under t r�provisions of 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: Valuation:$3500
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 APN Number:31630073.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section _
9.18.
RE-ROOFS:
Signature Date . Z l U All roofs shall be inspected prior to any roofing material being installed.If a roof is
ins.alled without first obtaining an inspection,I agree to remove all new materials for
ins Section.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,pnd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Ov,ner or authorized ag Date:
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I h,:reby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Le ider's Name
APPLICANT CERTIFICATION Le ider's Address
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
inion the above mentioned property for inspection purposes.(We)agree to save
mnify 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 I uiiderstand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
Building Department
City Of Cupertino
ELM] 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBI'ONTRACTOR LIST
JOB ADDRESS: /Vlt? P44,d�11271 ZY1 PERMIT#
OWNER'S NAME: PHONE# 'J
GENERAL CONTRACTOR: BUSINESS CENSE #
ADDRESS: — CITY/ZIPCODE:
"Our municipal code requires all businesses working int a city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY IM-PECTION(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:
Signal ure 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 CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: loot :
APN . . . . . . . . : 31630073 . 00
DATE ISSUED. . . . . . . : 05/24,2010
RECEIPT #. . . . . . . . . : BS000010466
REFERENCE ID # . . . : 10050:_74
SITE ADDRESS . . . . . : 10534 N BLANEY AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPER"INO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CHANG TRUSTEE
ADDRESS . . . . . . . . . . : 10534 N BLANEY AVE
CITY/STATE/ZIP . . . : CUPER7INO, CA 95014-2455
RECEIVED FROM . . . . : TOM TIAN
CONTRACTOR . . . . . . . : TRAN, TOM LIC # 20711
COMPANY . . . . . . . . . . : GREENFIELD PLUMBING
ADDRESS . . . . . . . . . . : 3513 DIADRID DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95132
TELEPHONE . . . . . . . . : (408) (-,21-8980
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----- ----- ---------- ---------- ----------
113CBSC VALUATION 3, 500 . 00 1 . 00 0 . 00 1 . 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 3, 500 . 00 0 . 50 0 . 00 0 . 50 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 148 . 50 0 . 00 148 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -- ------------------
CASH 148 .50 10534 blaney
---------------
TOTAL RECEIPT 148 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 507 FINAL PLUMBING
CITY OF CUPERTINO
~ REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
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APN# Date: ,
Building Address: _ �) Pc►l)
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Owner's Name: _ Phone#:
Contractor: _ Phone#:
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Contact: L Phone#:
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Contractor License#:
Cupertino Business License#:
Job Description: ,%
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Residential [ Cc mmercial ❑
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 11CPSS
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
REPIPE/SEWER/MAIN SERVICE
Of
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
l 1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pipe pei fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Dispo;;al System P
1PCESS Cesspool P
1 BPWATER Install/alter Water Pips; P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping; System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1 PLMBINSP Other Plumbing/gas Ir.sp. P
/ 1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B