12020015 02/06/2012 14: 57 6503425320 JAMES CACCIA PLUMBNG PAGE 02/02
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20900 ALVES DR CONTRACTOR:JAMES CACCIA PERMIT NO:12020015
PLUMBING INC
OVYNEWS NAIIJE: BURRIESCI LAWRENCE G AND JANIC 9X7 N AMPHLETT BLVD DA.T9 WSUED:02/06/2012
OWNER'S PHONE: 4082577519 SAN MATEO,CA 94401. PEON¢NO!(650)342.5363
j,,ICENOED CONTRACTOR'S D1;Ci ARA- )Y BUILDING PERiVIIT[NFP: BLDG ELECT PLUMBLicense Class C 3 Lie,.# �? S -9,a
MECH 1— RFsIUD)ZNTIAL I- COMMERCIAL
I hereby aftin that I am licensed under lite provisions ofCGApter 9 JOB Dk SCRYPTIQN:RErtiwCE 3/d"COPPER WATERLINE �
(mitutencing with Section 7000)of Division 3 of the Rusittess&Frofesaions
Code and that my license is to lull farce erred et3:ect-
I hereby sifirta tinder pcaaity of pe jtery one or the following two deeltratious:
I have and will maiutato a oed;fica(e of N)tvseet to self insure for Worker's
Compensation,as provided for by Section 3700 of the Gabor Code,for the j
poMunauce of the work for which this permit is issued.
I have and will maintain Worker's Compensation tnwrtwce,as provided for by Sq.Rt Floor Area: Valvatloa:$2000
Section 3700 of the Labor Code.for the perfbrmance of the work for which this
permit is issued. APN Ni(mber:32631009.00 Occupancy I Ype: !
i
I cettify that I have read this npplication and state that the above inforntation is
cannCL f agree to ernnply with alt city alld county ord irttutces arid state lawn,relating PERMIT LtpXS IF WORK IS NOT STARTED
to building oonshvctiott aril liereby atrthortze mproscntativcs of this city to enter
upon the above mendooed prop,rt5'for inspectiou purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and kap bnonless the City of Cupertino against liabilities,judgruem, 1$0 DA FROM LAST CALLED INSPECTION.costs,and expenses which ratty aocruo against saiQ City in consequence of the
granting of this permit. Additionally,the applicant understands and wilt comply
with all Aon-poan Source rcgulatiars per the Cupertino Municipal C9dc,Scotian SI[Sd by, Date:2` �
9.18.
i
Signature Date.If'y
- it . �R E ' AIt T N All roofs shall be In LtGltt)O>N'4:
spected prior to any rooting ruaterial being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for j
!hereby affirm That i am exempt fram Circ Contractor s Lleeuse Law for one a( inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole,epmpt L31160u, Signature of Applicant; Dsde: f
will do the work.w1d the structure is not intended or offered for sale(5ee.7044,
Busin=bi Professions Code)
r,as owner of trio properly,mint exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code). {
ll hereby Afllrtu under penalty of pajury one of the following three HAZARQQQ8 MATERIALS DISCLOSURE
declarations: I leave read the hazardotta neatertnls rtgWrernents under Clxepter 6.95 of the
(have anal with maintain a Cettificate of Consent to sctNllsure for Worker's Califbrofa ACRith&Safety Code,Sections;Z,5505,25533,and 25534. 1 will niaiOkakk
Conti*rtsation,as provided for by Section 3700 of Ute Labor Code,for the Com pliauce with the Cupertino Mtaticipal Code,Chapter 9.12 and the health 8r i
rpt rftninauce of the work for which this Inrmit is imtod. Safety Code,Sectioo 25531{0)sbvuld 16101.4 or handle hazardous enateNal.
V/1 have and will utaintaut Worker's Compensation,(usurauoe,as provided for by Additionally,should I nese equiprttent or devices which eioit hazardous air
Section 3700 of the Labor Cods,for the perfbiawuwe of the work for which this cuntaroinarils as defined by elle Bay Area Air Quality Management District I will
permit is issued. 11141ntala oompliance with the Capertiou Municipal Code,Cltoptcr 9.12 and the
I certify that in the performance of the wont thrwhioh this permit is issued,I sMt 1IealUt aft Safery Code,5eetioe►s 255415,25533,stud 25534.
not employ any person in any manner so as to become subject to the worker's Owner orSt tntttOtta eat;
COntpeus iOn taws OfCalifantia. if,atter rrtsking this certificate of exemption,I Date: a�
bet:onte subject to the Wotkec's Compensatiota provisions of the Labor Codz,I must J�
forthwith comply with svcb provisions or this penuit shall be destned revolted. COt�ST_RUG CION 1C.lEN!)]iVC.AGWt`Y (/
I hereby*(firm that thcre is a construction lending agency for the performance of wont's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I oatify that 1 have read this application and state that the above information is Leader's Nance i
eotroet-I agree to comply with all city and county ordirimices and State laws relating
to(wilding constntction,and hereby authorize«prescntn'tives of this city to enter Leoder'e Add,^eaa
upon the above tnetttiotted property for inspection purposes.(We)agree to save
iiadeinnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 6ECXMI 'E'S]DECLARATION
granting of this permit.Additionally,the applicant tnederstartds nod will comply I undo-stand my plans shalt be used As public rec9rds,
with all non-point source regulaticus per the Cupettiuo Municipal Code,Section
9.18. Licensed Professional
Signature Dave 6 r:..
CITY OF CUPERTINO
FEF, ESTIMATOR- BUILDING DIVISION
DATE: 02/03/2012 REVIEWED BY: A. Salvador
ADDRESS: 20900 Alves Dr.
APN: BP#:
r1i
VALUATION: $2,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRINiARY PENTAhIATION 1 RPWS
USE: SFD or Duplex PERMIT TYPE:
WORK Replace 3/4" copper water line.
SCOPE
Plumb.Plan Check FO.01 hrs $0.00
7 Plumb.Permit Fee: 1 PPERMIT
Other Plumb Insp. ED
hrs $44.00
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public{forks,Fire,Sanitary Sewer District,School
District,etc.). These,Lees are based on the erelininarl,information available and are onl an estimate. Contact the De t or addn'l info.
FEE ITEMS <5, . ,?sI _'< e' 1'b Ef ' 11-1 i s FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Plumbing
Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $22.00 IBP1 SVCS Water Service
PME Plan Check: $0.00
Permit Fee: $0.00
Srrppl. Insp. Fee-0 Reg. 0 OT 10,0 hrs $0.00
PME Unit Fee: $0.00
PME Per-mit Fee: $44.00
::
Administrative Fee: ]AD�i11V $41.00
Work Without Permit? 0 Yes Q No $0.00 fl
$0.00 Select a.Non-Residential }
Building or Structure
Travel Documentation Fee: ITRA VDOC $44.00
Sir LoIBSEISAKCR $0.50 Select an Administrative Item
B l °" !.tdc4.�.._.___rv"ni m- a's wn,F e' IBCBSC $1.00
SUBTOTALS: $130.50 $22.00 TOTAL FEE: $152.50
Revised: 1/19/2012
CONSTRUCTION PERMIT APPLICATION
10] COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•building aa)cupertino.org
❑NEW CONSTRUCTION ❑ ADDITION //❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS •, O/ ,;-1r� 1` `/t / APN#
OWNER NAME 9 f. I i f3 C� C ' P `� -] 7 5' � E-MAIL
ST �-\./ ES!3 L ZI f�!� FAX
CONTACT N D i P 0&, 3(ta 5 &5 17Kv 0 MM a b) .L
IJ
ST E DD TREE ��� CITY STA FAX ' l
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
NTRACTOR N M� LI SE NUMBERLtEKey
PE BUS LIC# .�
COMPANY NAME E-MA F�Jt? J 1'a
CA V, n rl ti m�i ►� c �r�/q I b
ST ET DREfIS, A f 4I- 1-C LJ� 11 C�IsK1TE7( �� it ` , ` Il `' L P'�E
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
l
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKNORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT LJ YES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? []NO
PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN E]YES RECEIVED BY: TOTAL VALUATION:
PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? []NO
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 1.doc revised 06/21/11