08100125 CITY OF CUPERTINO -
BUILGINVDIVI5ION PERMIT �CONTRACTCTR NI`URM.A.TION :
PERMfT NO.
Bu1LTIMTESSARALLONE DR WATER QUALITY PLUMBING 08100125
OWNER'S NAME: PERMIT ISSUE DATE
SCOTT & SABRINA ELLIS 1860 ALMADEN RD 10/20/2008
lip NE: (408) 267-9330 SANITARY NO. CONTROL NO.
ARCHTIECf/ENGINEER:
BUILDING PERMRINFO
BLDO ELECrPLUMB MECN
0 0 0 0
O O LICENSED CONTRACTOR'S DECLARATION Job Description
i� I touch, than affirm I un limnaed under provisions of ChapuOescrlp
r 9(commencing
with Section 70M))ofDiAsjqn 3 ofthe Busman and Profassions Cnde.and my liccnmb REPIPE, ADD GAS LINE TO REPLACE INSERT (MAIN
o }� in full fora and erfcn. ac ')
jpz LimruaClm Lm.0 PERMIT#08070131)
Damkwil2ri Conuxwr
ARCHITECTS DECLARA
� U l undersu r 1 e uj d u public sM
C IRcmtud Professio
OWNER-BUILDER DECLARATION
E 1 Wrtby a um that 1 am eumpt from than Contractors License law for do
C o O following memo.(Sacuon 7931-5.Beams;and Professions Code:Any city or county
which mquims a permit to conswcL ale.improve,demolish.or repair my mm.um
_Z} prim An its issuance.Alto requires tW applicant forsoch permit m file a signed statement
ESC Sq.Ft. Floor Area Valuation
Net heislicensedpurmntmnieprovisionsofNeContrmmrll.icenselaw(chapter9
yF$ (commencing with Suction 7000)Of Division 3ofthe,Business And PokssaomCode)or $5000
Q
that W Is eumpt therefrom and the breis for Also aileged eumptim Any violation of
Section 7031.3 by any applicant for.permit subjects the applicant An a civil penalty of Number Occupancy Type
not mart Nm five hundred dollars($50a). 369390371�(
0 1,a mw of the pmpcny.err my mploycu with mgesu Noir role compemdon,
will do thewoslt and Netwctuu is rot inundnd oroRered forum(Sec.7061,Business
And Pmfcaaons Code:The Commctors License law does oat apply an an owner of Required Inspections
property who builds or im proves thereon.and who does aueh.,it himself or through his
own cmployrrs,provided Wtsuch Wpmvements see notimmnded oroQerd forum.If.
however.the building or improvemmt is sold within arc year of completion.One owna-
Wiider will have the Instant of proving that he did rot build or improve for purpose of
Asks.).
❑1.As owner of than innpcuy.w euRusively croa acting with accused contractors in
annum the Poona(Sec.7044,Beacom and professions Code:)The Cosormars Li-
m law,dans not apply As an owmr of proWty,what Wilds or improves thercon.md,
who canuacu far suets patients with a emsummKs)reamed puruant to nisi Conan ar'S
lsem Law.
❑Imensemptunda See ,B&PCfosthfsmsson
Own. Data
WORKER'S COMPENSATION DECLARATION
1 hereby tin.under penalty of perjury,arc of the following dMantions:
I have and will maintain a CertiOeauof Comm m sill-insurefor Workers Campem
union,As provided for by Section 3700 of the Labor Cade.far Ne perfomunce of the
wuor/k for which this permit is issued.
scat have and will maintain Workrls CompemaUon ha orm ee.As required by Section
370D a the Latter Code.I.the per(oretanee of the,wort for which this permit is Wood.
My Workces.Coompensaation insuranceinsurancearia and Policy number AM::a�r�
Drier: JI-I11enIar�
G B Policy No.�3 7*3T1J�'(57
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(IhuseNm need not he Flood lithe permit is faux hundred da0ars(3100)
orlrss)
1 atily Nal in the Wiforan.of tW wank fm which this pemnit Is issued,I dull rot"
employ,any person in my mannerso As An Weems Object in the Woh Compensation
pawn of Caifompa.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certifucate of Exemption.you should
become subject an the Woh ra Compcmidou provisions of the Labor Cade,you mum
.J O forthwith comply with such provisions or is permit shall be deemrevolted.
alted..
zi 51 CONSTRUCTION LENDING AGENCY
E~ 1 Wuhy allium than dart is a construction pending agency for the micamanm of
GL r
the wank fm which this permit 4 Wood(Sm.3097,Civ.C.)
0.Q Landers Name
,J z faders Address
U O 1 certify that I have rad this ippiication W sum thv than above inf.madon u
py^. moan 1 agree as comply With All 61Y and money ordinm¢a W sale paws mladng In
C) Wilding commotion,and Wreby audeorim representatives of this city to now upon to
W above-mentioned property fee inspection purposes
(We)agree m save,indemnify red keep harmpm the City of Cupertino against r..t y Iiabilitiq judgmcus.costs and capemu which may in my way acave against said City
U z in consequence of the granting of that permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU R U A S.
1 Re-roofs
Sign a l'Applicam/Co.unsa w Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building ummpmt smm or handle h.amous material
As defined by nio Cupertino Municipal Cade.Chapter 9,pee.and the Health and Safety
Coda,Section 25532(.)7
Yes �N9 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding attvpant use equipment.devices which If a roof is installed without first obtaining an inspection,I agree to remove
.t huardous air conumimnu As dcfimd by the Bay Arta Air Quality Management all new materials for inspection.
Disuict7
❑Yes ®No
1 have mW dm hs amour maerias requimrronts under Chapter 6,95 of the Califon- .
nu HglNkSafety Cade Sxaau 25503,25533and 2553s.lundermmb thnifNc Wilding
docs rot tuner,y have a Amann.the it is my r.pomipility to notify the aaupant of the
nequimme wh It Iprior toi63amecor.CertifllcaearOccupamy. Signature of Applicant Date
Owner h accdegcnt Dam'
All roof coverings to be Class'%W'or better
CITY OF CUPERTINO
• 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36939037 . 00
DATE ISSUED. . . . . . . : 10/20/2008
RECEIPT # . . . . . . . . . : BS000006399
REFERENCE ID # . . . : 08100125
SITE ADDRESS . . . . . : 10605 FARALLONE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SCOTT & SABRINA ELLIS
ADDRESS . . . . . . . . . . : . 10605 FARALLONE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JON R CRASE CONST I
CONTRACTOR . . . . . . . : SATALINO, MARTY LIC # 21526
COMPANY . . . . . . . . . . : WATER QUALITY PLUMBING
ADDRESS . . . . . . . . . . : 1860 ALMADEN RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95123
TELEPHONE . . . . . . . . : (408) 267-9330
SFEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BPWSVCS WATER SERVICE 1. 00 20 .40 0 . 00 20 .40 0 . 00
1BSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PGASRES OUTLETS 1 . 00 61 . 19 0 . 00 61 . 19 0 . 00
1PRREPIPE NO OF FIXTURE 1. 00 10 . 20 0 . 00 10 . 20 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT : 133 . 08 0 . 00 133 . 08 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 133 . 08 #51297
---------------
TOTAL RECEIPT 133 . 08
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ------7--------------------- -------- ----------------------
301 ROUGH PLUMBING 507 FINAL PLUMBING
*CITY OF CUPERTIN60
�Q` REPIPE/SEWER/MAIN SERVICE
• CUPE�TINO PERMIT APPLICATION FORM
APN # n, 9 037-
2•17_ 6 J Date:
Building'Address:
ICDCoO5 = ID2
Owner's Name: Phone #:
SC01 + SAgR-I AA- mus (-406) 257--930 3
Contractor: Phone #: (40b) 310-14b5-
JDN 2 CRIA-&—s 00�3sF, t0c. Fax #: (� 3-70- 073b
Contact: Phone#:(40&,� %ab-o 4g c o e
`JJDHQ COO i 1
Fax #: (40k) 3r)o-0231°
Contractor License#: 305n19 i3P- DM1L= 21oq
Cupertino Business License #: 'LIS 2lo
Job Description: A C>(2t.316uW W j>,�zya,T U807o t3 1
'A"DD 2c1Pt Pv- ro (E) ' i T —
A00 6,e Gli st; 'I6 ft �:I-
esidential Commercial ❑
Valuation:
Project Size: Express 0 StandardW Large ❑ Major❑
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:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
j 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
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
RTY OF CUPERTINO
Zia REPIPE/SEWER/MAIN SERVICE
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
IPRREPIPE Residential re-pipe per fixture P 1RPRP
I 1BPWSVCS Water Service P 1CPWS or
IR-PWS
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
IBPGAS Gas Piping System 5+ Outlets P
IPPERMITFEE Plumbing Permit Fee Issuance P
IPLMBLNCK Plumbing Plan Check P •
IPLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel &Documentation Fee B
IBUSLIC Business License B
Revised 6-16-08
•