11120019 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21815 BENETTI CT CONTRACTOR:GREAT AMERICAN PERMIT NO: 11120019
PLUMBING CO INC
OWNER'S NAME: JENNY CHANG&YOUWAN KANG P O BOX 26942 DATE ISSUED: 12/022011
R'S PHONE: 4082426115 SAN JOSE,CA 95159 PHONE NO:(408)279-1515
❑ LMSED COT R'S DECLARATION r, F_ r
BUILDING PERMIT INFO: BLDG ELECT PLUMB "
License Class hM r rl r
MECH RESIDENTIAL COMMERCIAL
Contractor ( ate
I hereby alarm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL PROPERTY LINE CLEANOUT
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full farce 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.FI Floor Area: elualion;$1950
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 IcA P4
permit is issued. APN Number:32649032.00'_NV) Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating PiI SIF 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 TI-1 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, `4
costs,and expenses which may accrue against said City in consequence of the 180 D" S FROM LAST CALLED INSPECTION.
granting of this permit Aodin ally,the applicant un rstands and will comply /� �/�j
with all non-point source u at' s pe t to Cup unic ppaall Code,Sect' J Issued by: Date:
9.18. 1pl �—T/
Signature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material berg installed.If a roof is
1 hereby affirm that t em exempt from the Contractor's License Law far one of installed without first obtaining an inspection,I agree to remove all new materials for
Y P 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 stmcture 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).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: 1 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(x)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 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 1 will
permit is issued. maintain complma ith the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety, de, ectio 25505, ,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 O T" it(�! It f
fi 2�
Compensation laws of California. If,after making this certificate of exemption,I Dete:
become subject to the Worker's Compensation provisions of the Labor Cade,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constmction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
1 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
"nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accme 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
00
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M I
sc
• CUPERTINO (408)777-3228• FAX(408)777-3333• buildina(a cuoertino.orO
UMHING MECHANIC ELECTRICAL/� MISCELLANEOUS
PROJECT ADDRESS 1 / ; APNp /�� ,` ,`0j
X OWNER NAME o6 l/ n t�/�y "� I
/ STAEETADDRESS r/f v CITY, STATE,ZIP/!' FAX
CONTACT NAME PHONE E-MAIL
STREErADORESS CCT V,STATE,.ZIP ( FAX
A
❑ OWNFA ❑ O BtRIDFR WNFR A(RM ❑ WNTAA W
AGEtO87'ER G PER ❑TENANT
CONTRACTOR NAME C y D U3.LIC a
COMPANY NAME FAX
STREET ADDRESS CIfY, PHONO
ARCHTTECIENOINEER NAME IICENSEMMER t O EUS.uCN
COMPANY NAME' E-MAIL FAX
STREITADDRESS CITY,STATE.Z@ PHONE
SE OP ❑SED wOtTPIJDC ❑ MULTt-FAMD.Y PROIECTW WDDLWD 11 YES PRO=1N 13ES Yis THE ELDG AN ❑YES
BVBDWO; I3 WMMERCIAI. URBANWTERFACEAREA I3 NO PLOOD ZONE ❑NO Ecm-lat HOME? ❑NO
DESCRIPTION OF WORE
XTOTAL VALUATION: D RECEIVED BY:
By my signature below,I certify to each of the following: I son the property owner or authorized agent to act on the preperty owner's behalf. I have read this
application and the information I have provided is correct-1 hav d the Description o Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatingto buildin at1� au zo s Cu crtino to enter the abf}v entified/pro ert/y/f�r ms ectioo ui oses.
Signature of ApplimLiAgent I P Daze. p P P $
SUPPLEMENTAL INFORMATION REQUaED --„// OFFICE USE ONLY
m ❑ OVER-THE-COUNTER
6
❑ EXPRESS
Y
u
x
❑ STANDARD
u
❑ LARGE
6
❑ MAJOR
MEPAfucApp 2011.doc revised 06121111
• CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 32649032. 00
DATE ISSUED. . . . . . . : 12/02/2011
RECEIPT #. . . . . . . . . : BS000015473
REFERENCE ID # . . . : 11120019
SITE ADDRESS . . . . . : 21815 BENETTI CT
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JENNY CHANG & YOUWAN KANG
ADDRESS . . . . . . . . . . : 21815 BENETTI CT
CITY/STATE/ZIP . . . : 'CUPERTINO, CA 95014
RECEIVED FROM . . . . : THE GREAT AMERICAN
CONTRACTOR . . . . . . . : CORPORATION LIC # 18061
COMPANY . . . . . . . . . . : GREAT AMERICAN PLUMBING CO INC
ADDRESS . . . . . . . . . . : P 0 BOX 26942
CITY/STATE/ZIP . . . : SAN JOSE, CA 95159
TELEPHONE . . . . . . . . : (408) 279-1515
• 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 1, 950 .00 1. 00 0. 00 1. 00 0. 00
1BSEISMICR VALUATION 1, 950.00 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 #121254
---------------
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: 21815 benettl ct. DATE: 12/02/2011 REVIEWED BY: bobs.
APN: BP#: `VALUATION: $1,950
"PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
WORK install property line clean out.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $22
TOTALS: $22.00
3f"'h. Nan Cht' ; Plumb.Plan Check 0.0 hrs $0.00 fsGrn.Plan C KI.4
Nfech. Per+uri Fee: Plumb. Permit Fee: IPPERMIT v- Pe"mi!Fee:
. Othei d1ech lusp. Other Plumb Insp. 0.0 hrs $44.00 Ofljo F7er.. hnp.
,1 eeh.Inc). Pee: Plurrh. ln.>p./'rrr Ele.e.Imp. Fere
NOTE: This estimate does not Include fees due to other Departments(ie.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prellmina Information available and are only an estimate. Contact the Dept for addn7 infa
FEE ITEMS (Fee Resolution 11-053 E8 7/1111) FEE QTY/FEE MISC ITEMS
Plan C'llzc:k 1�ce:
Sup/il. heoF' e
PME Plan Check: $0.00
Permit Ree
Suppl. lnsp Pee
PME Unit Fee: $22.00
PME Permit Fee: $44.00
Cnnstruclion Tax
Administrative Fee: (ADMIN $41.00
Work Without Permit? Yes 0 No $0.00
'Idwinced Planning Fc s,
Travel Documentation Fee: 1TRAVDOC $44.00
Strove Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
. Bldg Stds Commission Fee: iBCBSC $1.00
SUBTOTALS: $152.501 $0.001 TOTAL FEE: $152.50
Revised: 10/01/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
U P E RT I N O Fax: 408-777-3333
CO T TO�t / UBCONTRACTOR LIST
JOB ADDRESS: PERMIT# DO
OWNER'S NAME: O HONE# D
GENERAL CO TR CT USINESS LICENSE#
ADDRESS: �ITY/ZIPCODE•
*Our municipal code requires all businesses working in the c' ale a City of Cupertino busines license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCON RAC HA OB ED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
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 ! d
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
WI/r/
Owner/Contractor Signature Date