03120004 CITY OF CUPERTINO rbsur' e ^'+'r¢ti# z
PUILDING,DfVISION PERMIT ,C5fONTRAC`�TOR NFORMATION:
a' c ss
BUILDING ADDRESS: ABLE SEPTIC PER MIT NO03120004
P19 KIM ST
VsR'S NAME: PERMIT ISSUE DATE
FENNIFER Se LUSENS PANN 520 REED ST 2003
PHONE: SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHITECT/ENGINEER: BUILDING PERMITINFO
ELDOELECT PLUMB MECH
0
j O D LICENSED CONTRACTOR'S DECLARATION
1 C 1 hereby affirm that 1 em licensed under And
Potions of mChopmr 9(commencing Job Description
b with 5ectiun]IIf10)uf Divixion Sof NC Business and Profcssinm Code,and my license is
��? infullfnmlygLcIf OL 77H7j; SEWER LINE/CLEAN OUT
Licenu Ct Z L'.
F Dem J _ / Ctumaese fTW 5
ARCHITLCTS OEARAT10N
e 2 I understand my plans shall M UUJ ax public re,mb;
6
e tae Licensed Professional
1
OWNER-BUILDER DECLARATION
2 2 1 hereby.(firm I oto aurin from the Contras C License Low for the s
p p far whiclowing requires
es ossa.farra(SectionIDns6.Business and
Rdemolish,
h,or.Any city stcounty
$ whichm Ircea ,alsore construct.alter.improve,h Permits sure sire xtmmum
poor In issuance,also requires the applicant for such Permit 0lcesignctl statement r ,
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapmr 9 Sq. F " b` Ara `^c-J Va at10n
$ (commencing with Section 7(XX))of Division n of the Business and Professions Code)or I �'
Nat he b exempt therefrom and be buil for be alleged exemption.Any viola
don of f
Section 1071.5 by any applicant for a permit subjects the applicant to a civil penalty,of
not mon Nan five hundred dollars($300). O --.� Occup nay pe
I,uowncr of Nen ye p ytes w' ges pen r
❑ p prruc mm m to tbwa sfor ale(Se le core alien, 1
will dofessor CdNc swansisnmiLiceeseol Law does
dsnot apply 7044.Business
of Required Inspections
And property
obu Codc:The Contnctora License Law dors not apply tom owner of q p
own ewho proorimproves ch improvements
doessuchwork himselfedthrough his
own employees,er.be provided then such improvements are not ear D(d oro0ered for Asia,If.
owner-
however.she building or improvement is hold a within one year D(completion,ove for be owe of
Mlej,r will have Use burden of proving Net he did not Wild or Improve for purpose of
sale J,
❑1,as owner of the pmpeny,em exclusively contracting with licensed conhacton to
consumer the project(Sea 7044,Business and Professions Code:)The Coauacmes Li
ave law don not apply to an owner of progeny who builds or improves Jremon,red,
who contracts for such projects wish a contracter(s)licensed pursuant to the Convinces
License Law.
❑I am exempt or&,Sea. ,E&PC for Nis mann
Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of be following declarations:
❑1 ban and will maintain a Ceniocare of Consent to self-insure for Worker's Compere
savion,As provided for by Section 37M of the labor Code,for the performance of the
work for which this permit is issued. -
❑1 hale and will maintain Workers Compensation Insurance,As required by Section
3700 of be labor Cod.,fm be Nora....el be work for which Nis permit is iaocd.
My Workees Compensation lnsurmes cared,,end Polity morals, _
CERTIFICATE OF EREMFf10�M WORKERS'
COMPENSATION INSURANCE
(This section need not be completed RJr'Permit is intone hundred dollars($Hg)
less.)
I cenify that in be performance of be work for which this Permit 0 issued,l shall not
employ any person in my manner an as to become subject to the Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,.(ter making this CeniOcate of Exemption,you should
become subject to the Worker's Compensation PIa MDIs of be Lmur Code,you must
❑O forthwith comply with such provisions or this Permit shall M deemed mvoked.
zM CONSTRUCTION LENDING AGENCY
I hereby affrnn bar Nem its construction lending agency Cut the Performance of
x> ba work for which this permit is issued(Sec.3097,Civ,C.)
Q Under's Name
z Lcnoees Addreser
(.7 0 1 cenify bat I haw read this application and mm that the Above inrmmNon is
correct I agree to comply with all city and county ordinances and stare laws relating to
Obuilding construction.antho
And hereby aurize repreumidws or this city to enter upon one
(')
Uebovomemiuned property for inspection purposes.
(We)agree Is ave,indemnify and keep harmlea the City of Cupertino against '
% Rabililics,judgments.core and expenses which may in any way aceme against said City /
V 7 A APPLICANT
of the grouting of this D WILL
G APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date r
SOURCE REGULATIONS.
/Z Re-roofs
�
S tura of Applicam/Comrumr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Jre applicant or future building Occupant store or handle hamduus material
III e Med by Ne Cupertino Municipal Cade,Chamo 1,11,and she Health and Safety
azss3z(')!
0Yea P(Ne All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emd h....door air contaminants As bRosd by the Bay Arca Air Quality Management
DivoctT all new materials for inspection.
❑Yea J�Nu
1 have read the hzvaNrms materials mquirtments under Chapter 6.95 of Ne all rm-
.I.Health&SafctyCmb.Sections 25305.75533 and 25534.1 understand Nor if be building _.
does rent currently haw a tenant that it u my rvpovibility m nod I Use occupant of be
requirements which most W met prior to issuance of a Ccrdfcatco(Occupmey. Signature Of Applicant Date
rl3 n f7 2 -a;-o3 All roof coverings to be Class "B" or better
rmauthorizcJ agent _
Data
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM 031 R00I11
APN# Date:
Building Address:
91q Kim S7—
Owner's Name: / , , __� Phone#:
Contractor: Phone: License#:/ 7 �7S
/►3le tie� �c CkoV 3 77- 99go (Q
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ) 17
Job Descripti C� Cf / 95fC-_() /-7 Z-
Residential_ Residential-A, Commerci ❑
Cos of Project:
Qty. if
App-rileable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•
• CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35920003.00
DATE ISSUED. . . . . . . : 12/01/2003
RECEIPT #. . . . . . . . . : 23929
REFERENCE ID # . . . : .03120004
SITE ADDRESS . . . . . : 819 KIM ST
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JENNIFER & LUSENS PANN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4322
RECEIVED FROM . . . . : JENNIFER PANN
CONTRACTOR . . . . . . . : GILBERT, GLEN 'LIC # 21407
COMPANY • ABLE SEPTIC
ADDRESS . . . . . . . . . . : 520 REED ST." '
CITY/STATE/ZIP . . . : SANTA CLARA, - CA- 95050
• TELEPHONE . . . . . . . . : (408) 377-9990
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
. ----------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 1,500.00 77.00 0.00 77.00 ...' '01:00
BPSEWAGE UNITS 1.00 62.16 0.00 62.16 0,.00
PPERMITFEE FLAT RATE 1.00 35..52 0.00 35.52 0'.00
BPSEWER SEWER SYSTEM 1.00 19.98 0.00 19.98 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 194.66 0.00 194.66 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------___---------
CHECK 194.66 1017 .
TOTAL RECEIPT 194.66
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
DER:
•
CHB:
CV:
File:
CUPERTINO SANITARY DISTRICT
20065 Stevens Creek Blvd., Bldg. C
Cupertino, California 95014
(408)253-7071
"ON-SITE REQUIREMENTS-OVER THE COUNTER REVIEW"
Date: 1tm a oil Z/oo
File: CuSD MOP
Building Dept-Cupertino
Community Development Department-Building
City of Cupertino
10300 Torre Ave.
Cupertino, Ca 95014-3202 ``II //,, /�n (� /�
RE: Subject: Cf& CI" (W AU
Approved dor Issuing Name: Tmirm mo
Address:011 VIM 15 TKT r
Building) Plumbing Permits APN: 3r�o(� 00. 003
• Control/Plan Ck No.:
Permit No.: sJ
The Cupertino Sanitary District has reviewed the plans for the subject project: l/
Vo additional conditions/requirements by the District.
Sanitary sewer is available and the existing building is connected to sanitary
sewer, see conditions/requirements listed below.
❑ Sanitary sewer is(not) available, see conditions/requirements below.
❑ Sanitary sewer is not provided by the District, please contact the City of
Sunnyvale at (408) 730-7510.
The following Conditions/Requirements are made:
❑ Install new Property Line Cleanout or locate and raise to grade an existing
property line cleanout. Cleanout shall be the same diameter as the street portion
of the service lateral (Minimum gravity lateral is 4" diameter).
Video Inspection of the Property Line Cleanout,Point of Connection and Street
,• Lateral is required prior to passing The City of Cupertino Final Inspection.
Owner to call District 48 hours prior to video inspection to schedule a District
Inspector. District to provide Building Department with Written Notification
upon completion of Inspection.
Page 1 of 2
"ON-SITE REQUIREMENTS-OVER THE COUNTER REVIEW'
RE: Subject: IN U/ P�� Gv.w,I -OLtT
�1'�v
Name: m�'Cir' �NIV
Address: 8 M K 5 TKF:�/'T
APN: - 710-603
Control/Plan Ck No.: /
Permit No.:
CMM) G0NKTIoN f T � ��
❑ Inspection of Street Portion of Sanitary Sewer Lateral by the District, Please Do
Not Inspect and onsite construction prior to clearance in writing by the District.
❑ Owner to have a Civil Engineer fix the lowest finished floor elevation, with
plumbing, to the rim of the next upstream manhole. If the lowest floor with
plumbing is less than (1') foot above the rim, a Sewage Pump may be required.
• ❑ Cupertino Sanitary District Fees or Permits are required for the subject
improvements Please Do Not Issue any building permits.
❑ Plans shall be reviewed by the Industrial Waste Division of the San lose/Santa
Clara Water Pollution Control Plant Phone 945-5121 for questions and to
schedule a plan review appointment. Please Do Not Issue permits until
pretreatment recommendations have been forwarded to you by the District.
❑ Verify existence and serviceability of an existing backflow protective device.
❑ Break areas authorized minor electrical appliances only. (No commercial
disposal or commercial dishwasher installations.)
❑ Other:
Storm water form surface or roof drains, other general surface runoff water or condensate
form any residential HVAC equipment shall not be discharged to the sanitary sewer.
NOTE: Contact CuSD for"OFF-SITE REQUIREMENTS"
• By: uw&ac�
Page 2 of 2