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11110115 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20062 NORTHCREST SQ CONTRACTOR: MIKE COUNSIL PEBmi'f No: 1 11 101 15 PLUMBING INC OWNER'S NAME: COURTNEY GLORIA 1915 O'TOOLE WAY DA'Z'E ISSUED: 11/21/2011 ER'S PHONE: 4089187134 SAN JOSE, CA 95131 PRONE NO:(408)272-4900 LICENSED CONTRACTOR'S DECLARATION r r r � ��p�� qq B1111.DINC PERMITINFO: ULUG ELECT Pl.uaus License Class'-`�"-�hyl Lie.4 to-MZ� r r r M�� __- 11 -V - 11- �IF.CII RESIUN.NTIAI. CO FRCIAI. Contractor 1 AM�1 B.Date 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 .IOB DESCRIPTION: PROPERTY LINK CLEAN OUT (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in fall force and effect. hereby affirm under penally of perjury one of the following two declarations: 1 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: Valuation:520000 . 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 AI'N Numner�+: 63 bl` 0 Occupaney'I'ype: permit is issued. � lie tom' APPLICANT CERTIFICATION `� I certify that I have read this application and stale that the above information is PERn'IIT E PIRES IF WORK IS NOTSTARTED 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 FIWM 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 Date: granting of this permit. Additionally,the ap ant understands and will comply Issued by: with all n n- 'nl sou cc re le on r the IPcrtino Municipal Code,Section 9.18. Rt:ROOFS: Signature Dalc� I All roofs shall be inspected prior to any rooting material being installed. II a roof is installed without fust obtaining an inspection,I agree to remove all new materials lin inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Data hereby affirm that I am exempt from the Contractor's License Lnw for one of the following Iwo reasons: ALL ROOF COVERINGS TO BF.CLASS"A"OIt BETTER 1,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 I AZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 695 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury one of the fallowing three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Ilealth&Safety Code,Section 25532(x)should I store or handle hazardous I have and will maintain it Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or de ices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined a Bay Arca Air Quo' y Management District I performance of the work for which this permit is issued. will maintain compliance wi a the erli In ip Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,S no II- 25 in d 5534. Section 3700 of the labor Code,for the performance of the work for which this Owner or xmhorized agent: Date: L permit is issued I certify that in the performance of the work for which this permit is issued,1 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 CONSI'RI1CI-ION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby union 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.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and stale 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 upon the above mentioned property for inspection purposes.(We)agree to save ARCHITFCT'S DECLARATION Inmify and keep hamrless the City of Cupertino against liabilities,judgments, s,and expenses which may accrue against said City in consequence of the I understand 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 Dale CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM • COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 31637015 . 00 DATE ISSUED. . . . . . . : 11/21/2011 RECEIPT # . . . . . . . . . : BS000015363 REFERENCE ID # . . . : 11110115 SITE ADDRESS . . 20062 NORTHCREST SQ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER COURTNEY GLORIA ADDRESS 20062 NORTHCREST SQ CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0512 RECEIVED FROM . . . . : COUNSIL PLUMBING CONTRACTOR . . . . . . . : MIKE COUNSIL LIC # 32186 COMPANY MIKE COUNSIL PLUMBING INC ADDRESS 1915 O'TOOLE WAY CITY/STATE/ZIP . . . : SAN JOSE, CA 95131 TELEPHONE . . . . . . . . : (408) 272-4900 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 13CBSC VALUATION 20, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 20, 000 . 00 2 . 00 0 . 00 2 . 00 0 . 00 1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1ERT<200 UNITS 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 176 . 00 0 . 00 176 . 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 176 . 00 amx --------------- TOTAL RECEIPT 176 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 M ' sc •CUPERTINO (408)T77-3228 • FAX(408)777-3333• buildinaCcDcuoertino.oro L�UMBING MECHANICAL ELECTRICAL MLSCEL /AsNEOUSS I OI 15 FROJECTADDRESS s f� A , /IN# N� / 3-L{ 0I J/ IINERNAME r, P 14o •-41 1 1 3,14E-MAIL SRIEBI'ADD2 . 2 , STATE,ZEP �Sb) FAX CONTACT NAMP� PHONE, 1 E-MAIL EET STRADDRESS CITY STATE, FAX k 13OwNER E3OWNER.sur DER 13OWNERAGENT OTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 13DJ ENGEER 11DEVEJDPER 11 TENANT NTR.ArN ny\%NL. I h LICENSE FR LICENSE TYPE BUS.LICa IV COMPANY NAME E-MAH- FAX �DAES9 CITY,STA v �. PHONB 72 ARCHTCEC IENrINEEK NAME LICENSE NUMBER BUS.DC N COMPANYNAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE E OF ❑SFO.DUPLEX ❑ MULTI-FAMILY PROJECTBJWIDLANI ❑ YES PROIECTIN ❑YES DTHE BLDG AN ❑YES ING: ❑COMMERCIAL URBAN INTERFACE AREA O RMD ZONE ❑NO MCHJIR HOME] ❑NO OESCA@TION OF WORK 1 G O TOTAL VALUATION: ' RECEIVED BY: By my signature below,I certify to each of the following: I a n the property owner a authorized agent to act on the property owner's behalf. I have read this application and the information 113 va p vide is co cLd have ren a Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and some laws relating buil cos eti rim as of Cupertino to anter the above-inddeeati'iflod {1ope�ty for inspection pu( ores. Signature of ApplicanVAgent� Date: I I- H - 4 1 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY w ❑ OVER-THE-COUNTER y6 F ❑ EXPRESS Y U _ ❑ STANDARD - O 3 ❑ LARGE a. ❑ MAJOR M&PMircApp_2011.dcc revised 06121111 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3229 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: sa PERMIT# ( IIS OWNER'S NAME: w4LAIA PHONE# l$ •-713 GENERAL CONTRACTOR:MIV*, CpjyyzjL- 'VLUyh0l BUSINESS LICENSE# (D-T 2.(v I ADDRESS:t0Il CITY/ZIPCODE: *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 ALLNTRACTORSO HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: l l 1 1 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 Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date