08100086 CITY OF CUPERTINO
BUILDING MVISPON PERMIT CC1NTRACTORINFORMATION-,
BUILDING ADDRESS: PERMIT NO.
21921 ALCAZAR AVE SPEEDY ROOTER PLUMBING 08100086
OWNER'S NAME: PERMR ISSUE DATE
HESHAM IBRAHIM 701 ALDO AVE STE 43 10/16/2008
�NE: (408) 234-8134 SANITARY NO. CONTROL NO.
�
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
rpp
LICENSED CONTRACIOR's DECLARATION Job Descri non
ur 1 hereby affirm that I am l�tsed under provisions of Clepvl9(commencing P
with section 70 I)of Division3of UtcBumnmandProfeuimuCoda.mdmylie..1. SPOT REPAIR ON SWR LATERAL LINE CLEANING
i
on full force and effem.
LKe. ys Le.. 7 3
=F0 Dam Contrazmr fed2l&Ze
wwwy ARCHITECT'S DECLARATION
< 1 undersunJ my stair shall he used as public recants
u
g H
Licensed!Professional
a OWNER-BUILDER DECLARATION
ef 1 hereby affirm that I am exempt form the Convector's License Law for the
00 following mason.(Section 7f131.5,Business and Pmfesions Code:Any city or county
K m V which mquires a permit to construct,admit,impmwe,demolish,m repair any awmum
in Prior 0 is vsuance,sm mquims the applicant forsuch Permit On file a sigocil samment
< that he a licensed pumuantto the provisions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation
I (c
y ommencing with Section 700M of Division 3 of the Business and Professions Cade)or $4000
y;$ that he is exempt therefrom and the basis for the alleged exemption Any vidauon of
Section 7031.5 by arty applicant far a permit mbjcas the applicant in a civil penalty of Number Occupancy Type
not mom Nita fire hummd dollar(5500). 3 5 715 0 9 9 .'°t�l,N
I,as owner of the prolswtY•mmy mvployw with wades as mev sole compcnaation,
will do the work,and the structure is not intended or.Rered forme,(Sce.70/6,BUaness Required Inspections
and Pmfes am;Code:The Carom's Liana Law dm net apply N an Owner of q P
propertywW Wilds crimprow thecem.ti d whodoessuchwarkhimsrlrarduough his
awn employees.provided Can stcWmpmwemerms am amtimmndm oroRered forsale If.
beramm,the Wilding or impmwenoent is sold within are year of mmpleum,the owner-
Wilder will have the When of proving that le did net Wild or improve for peopsase of
sale.).
1,as Owner of the property am uclusiway contacting with licensed contrarian in SAN apnatmmthees act (Sec.in a 9unnessandity whose Cade)The Consw:mr'3 rid ��whoa law does wt apply m an owner of Proper(vice Wilds or en,rovo thereon.and wW cantrscs(arsucb pmjeca with aconvactorts)licraad puntiam m the Contractofs
0 1 son==or❑lam aempt under See ,08PCfor this maven
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury me of the fallowing declam0ona:
I hsm and will matmm.a Cenifeme,if Consent to self-inaum fa Worter'sCmopen-
.,as provn kci for by Sccvon 37M of the labor Code,far the part...of the
work for which Nis permit is lattice.
1 haws said will mainNm Worke/a Compeiwuon Irwran¢,ss I gOimd by Section
3700 of the Labor Curie,fOc the performance of the words for which ms perms is issued
My WOrrrrrkkkkkaymmmy••• C/a/mp/en's�asan Omer and Polity nr4l�nC(er�am: �•a
Cmiar.�2/y � Policy No. }!T"-I (.r O' . S q
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
musseed.need net becompleed if the permit isforone Wndmd add.($100)
or loss)
I certify that in the terfmmaxc of the work for which this Permit is satned I shall not
employ any person in any sooner an as to became subject in the Workrs'Compewtion
laws of CadBomiz.De•-
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifia¢of Exemption,you sbouldi
become ambient to the Workch Compeeaadan prevision,of the tapir Code,you mum
.,O foMwvth comely with such'inaddna Oc this pamat shall W dremee rtwkcd.
'Z'y CONSTRUCTION LENDING AGENCY
[-� 1 hereby aRrna him them is a rnmurcrnn lending agency for the performance of
!Yi > me work In,which ths am ml is aimed(sac 3094,Ch,C.)
W 0 IandarsNam-
7 z larders Amer• '
U O 1 certify that 1 have mail this application and nom mat me aWm inramudmt is .
I2.P C L 1 agree to comP1Y with all city and county ONinanera and a=Ian relating m
Q U Wilding conviction,and hereby a thonme represenatims of this city to eater upon the
4 ahowe-men urp
tioned Pmpetty far inspection poses
(We)agree in save,indemnify and tees hales de City of Cosentino against
rfn Imbilimi,judgmenss.cW end emevu which may,.my way Omuta against said City
U aZ in consequence of the bmntin6 of 's
'--'
APPLE ERSTAN AND WILL yyy�.QLY WITH ALL NON-POINT Issued by Date /GAF
5T10N5
10—(7-6V _Q .
e Re-roofs
Si pphanUCa V pale ---/
S M A s paaosuRE Type of Roof
w0y me,Cpe.. Wit rigs.Clasptaomnr NnNC hazaNOmmamrial
as defined by to 2(al? unuipal Code.Clasper 9.12,and!the Healm and Safety
cme.s«tiansss3z(a)7
❑YU 6N rN o All roofs shall be inspected prior to any roofing material being installed.
will the aPPhaant or revere Wading acompant tier egmpment or aewiroa which If a roof is installed without firs[obtaining an inspection,I agree to remove
hvallom nit conumtmns as dcfance by the Bay Ama Air Quality Management all new materials for inspection.
❑Yes fYMo
Ilona mail the hvutlws masraaismgmmmems un@r Clop iO6,95 oft he Califor-
nia1@ &SafmyCode.Smlwu25%5,25533wW25336.IurWCmuM ifft tutting
does net cwmndy ham a aman.thin it is my responsibility m reify me Occupant of the
mgmmemen must be ormissnanrcoI Carnal of w^ry Signature of Applicant
�� ✓H/l/L� %t 6� Date
owner man, t Dam.
All roof coverings to be Class'%¢"or better
v
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35715099 . 00
DATE ISSUED. . . . . . . : 10/16/2008
RECEIPT # . . . . . . . . . : BS000006363
REFERENCE ID # . . . : 08100086
SITE ADDRESS . . . . . : 21921 ALCAZAR AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HESHAM IBRAHIM
ADDRESS . . . . . . . . . . : 21921 ALCAZAR AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SPEEDY ROOTER
CONTRACTOR . . . . . . . : SPEEDY ROOTER PLUMBING LIC # 23086
COMPANY . . . . . . . . . . : SPEEDY ROOTER PLUMBING
ADDRESS . . . . . . . . . . : 701 ALDO AVE STE 43
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95054
TELEPHONE . . . . . . . . : (408) 234-8134
OFEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- -------- ------ - --- -- ----- --------
1BSEISMICR VALUATION 4, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1. 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRSEWER UNITS 1 . 00 20 . 40 0 . 00 20 . 40 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 102 . 48 0 . 00 102 . 48 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------- ------- --------------------
CREDIT CARD 102 .48 VISA
---------------
TOTAL RECEIPT 102 . 48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ------------------- - -------- ---- ------ -
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
4100 v �(o
CITY OF CUPERTINO
' REPIPE/SEWER/MAIN SERVICE
e CUPEfll PERMIT APPLICATION FORM
AP N,# 2S / /,5 D � ( • & Date: � D ` /<—("L
Building Address:V l - ( � n
Owner's Name: /(� Phone #:
Contractor: Phone 5y
Phone#: Z (J_o-74 ��(J
JY'/51 1 Fax #:
Contact: Phone#: 4;46& 7v6—&-9-73
Fax #:
Contractor License#: 331
Cupertino Business License#:
Job Description: 5; rbT WA UL
Residential Commercial El
Valuation: T-1
kood �d
Project Size: Express Standard ❑ Large ❑ Major ❑
t 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: V
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
/ 1BSEISMICR Seismic Residential P J
IPRSEWER Residential building P 1RPSS
�' sewer/sanitary sewer
CITY OF CUPERTINO
REPIPE/SEWERIMAIN SERVICE
CITY OF
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit,Type
Group
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture p
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
iPPERMITFEE Plumbing Permit Fee Issuance P
/ 1PLMBLNCK Plumbing Plan Check P •
1PLMBINSP Other Plumbing/gas Insp. P
` 1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
Revised 6-16-08
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