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08110039CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRAC ",' IA ... .. ATION ,,, BUILDING ADDRESS: PERMITNO. 22706 MEDINA CT DRAIN DOCTOR ominniq' OWNER'S NAME: PERMIT ISSUE DATE r)NE: A CONTROL NO. (408)37.0-3082 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSEDCONIRACIOR'S DECLARATION Job Description P . 1 hereby affirm Nal 1 am licensed under provisions of Chapter 9 (eommeming with Section 7010) OfDiA,km Sof dee Business sed ofessams Cove. my lice. is k ren rcg:w r- INSTL SEWR PROPTY CLEAN—OUT . n.a Lk.L ��;u Dam Danlracur crs DECLARATION 1 understand my plans shall M used as pool!. rtcm is Licensed Pmrectional OWNER-BUILDER DECLARATION I lmreby alflm Nal 1 am exempt from IM Comraaars License law for the following mason. (Sechom 71D 1.5. Business and Profession Code: Any city or county which rtqulrca a permit to construct, alar, improve. dcmo0.sh, or mpan any swclum pritr uh its imuaMY, also rtgnlm the applicant for such permit in rile a signed statement CmVCWra Lk--law(ChapLLT9 Sq. Ft. Floor Area Valuation thL hen licensed p..t to the provisions of YC feco mm,am, wide S.W. 7000) of Division 3.1 the Busnwu and Profeuimts Code) or 2 2 0 0 that M u exempt therefrom and 0o Mrs fm me alleged exemption. Any violation of APN Number Occupancy Type Schon 7031.5 by any applicant rm a Permit subjects No applicant m a civil penalty of not mom duo flux hundred eollan (Lsm). 34215055.00 Lo ow wnlryeedwith wgnsudeebsuk 7 sstions Required Inspections and, structmmy 44,B win dolMwoh. and. structure srelkundcdm ed her 7Oaa. naaensa work. Law doe, rel apply lf an owner cane: The License Lao, it= apply and Prty 9 P is wh Ire m thereon. and who areaamh workhimulfcrthrough his property who buildsori eno awn cmpkyouiprog d do, s ch improvements; are not iemndWmoRered or INatsuchimpmsoldwi be,for rear(. thebuildinganeproeemerds sold theose didarc year of mmove . foroo. Wilde,howeve of builder will have dee buNut of proving dist M did ret lxtiW m improve for puryose of a I. rose owner of dee property, conuanins :) conwcmrs to 1 rycmuwn R�IJ Thea .B simma a d Cod the project (SecW BucM... ane Cadei The Comctums. IIILi- rty whens ndV111 eeme LaW emJ am apply b an oWnel D( plapCllY w'na baile3 ase ImpmYCe BI[n'An. arid. as 111'` who mmncu (m such DmFcu rode a rnnuamar(s) licensedpunuant b IM C.nlracl.rs .tu,c SAN License Law. s-r _❑ ❑lam exempt under See ,BkPC fm des recon Owns Dau WORKERS COMPENSATION DECLARATION I Mrcby afRm under pceadly of perjury ore of the following dalarmions: 1 ham and will mainuin a Ccrolhouof Conant m ulr-insure for WonersCompen- on, as provided for by Sceaon 3M of the labor Code. fee the performance of to Werk for which this permit is issued. O 1 Mw and will maintain Walkers Compensation Incumbent, aS bum ed by Section 3700.(be Labor Code. for the performanse ofthe it for which des permit is issued. ' My Workers pen ado. seance amim and Paliey number Cartkr. kliry No.: D CERTIFlG FX P170N FROM C URA ICE (ThsseNonuee relMampleod: pemltls feranchunemEeollam($100) Or less) I ceNfr thet k the pmformena of IRm work for which this permit is hated. 1 anal: Out employ any pcower in any manure as to baumo subject to the WorkaY Compensation Laws of Caltfomia Dau Applicant NOTICE TO APPLICANT: If. after making this Ccntfiam of Exemption, you should become subj., to the WarkeYs Cempcnutinn provisions Of the Labor Code, you mu r v fortwitn comply with such provisions or this permit shall be dcemW rooked. CONSTRUCTION.I.aued. le(stt,.g nY I hereby this then s a coi lending agenry for dee perfomence.f cEm (SOe.tim a ase Wan sere When Ila, penin is iuma (sur. 3097, sur. c) jnder'sName U L<naera Aeare:s 1 certify that 1 have lead this application and suss del the above information is ^ comm. I agree w comply with all city and county ontinances aha suss laws relating to Wilding construction, W Mmbg aminsiw repmaemaws of ths city to enter upon dee G a1-mcnYOMd property for Inspection purposes (We) agree to un, indemnify Nd them, hamlea the City of Cupertino ags ul r4j Iiabilitlea,Judgment. caau and expenses which may in my way accrue against said City ) //719i in consequmo. of the Lraoing of ths permit.6( ^ APPLICANT UNDERSTANDS ANP_ ILL C MPLY WITH ALL N N-POINT SOURCE REGULATIj1NB:1�� Issued by: Dat ��— D ` I Re-roofs Signature of Appliam/Conuubr Do HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will theappliautaluwm Wilding occupentatercmhand hvallonsmawrial V. as ached by the Cupeniho Municipal Code. Chapter 9.12. and the Health and Safety Code, Sermon 255324)7 All roofs shall be inspected prior to any roofing material bein in all ❑Ya No If a roof is installed without first obtaining an inspection, I agree [o remove Will the applicant car fut m Ilaing occupant us wtipmmt o<devi¢� which it ha ard.ns ilr cant,minanu, rhea by IM Bay Ata Air Quality Management all new materials for inspection. Funcl❑Ya . e I have read dic menuunderCMpur 95 CitWilding .255da,25533 OuifIM hhh Safety . Sa9ou 255U5.255JJ ou12553C.1uMcnund Naz Btim building does ret eumnhi Mux a.name IMI it . responsibility m fy do aavpent of IM doesn ave be M rcymremcnB mupbamcc r;iamnreancemramaraa altry. Signature of Applicant Date //`—'— U All roof coverings to be Class'%r}.a' or better Ownv antthoriud qcm Dam • 4 ITEMS OF 4 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34215055.00 DATE ISSUED.......: 11/10/2008 RECEIPT #..:......: BS000006584 REFERENCE ID # ...: 08110039 SITE ADDRESS .....: 22706 MEDINA CT SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: JEAN MARIE MERKHOFER ADDRESS ..........: 22706 MEDINA CT CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2670 RECEIVED FROM ....: DRAIN DOCTOR, INC CONTRACTOR .......: JOHN H. LIM LIC # 24784 COMPANY ..........: DRAIN DOCTOR ADDRESS ..........: 1775 WINCHESTER BLVD CITY/STATE/ZIP ...: CAMPBELL, CA 95008 TELEPHONE ........: (408)370-3082 • FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL IBSEISMICR VALUATION 2,200.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 40.79 0.00 40.79 0.00 IPRSEWER 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 ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 102.48 --------------- 102.48 VOICE ID DESCRIPTION -------- ---------- ------------ 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING 0 REFERENCE NUMBER ---------- #1492 VOICE ID DESCRIPTION 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL 17 ' CUPERTINO r L CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM 0Ji/ 0039 APN #Date: qa/ ��.-� Fee ID Building Address: 0 Permit Type Owner's Name: Lp-e- "Q,r�-h Phone #: Contractor: D }�O � vi � o L-�-CJ Y— Phone #: ! _ Q g -i '� 3 2� o 1PCSEWER Fax #: P Contact: C K Phone #: sewer/sanitary sewer Fax #: Contractor License #: 1BPREPIPE Cupertino Business License #: P Job Description: ihs�1I serve-- p-orev--(-- cK oLi� Residential Commercial ❑ Commercial Gas Piping System Valuation: ,)_-'L- 4 m g� Project Size: Express Standard LI 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: 1BSEISMICOM Quantity Fee ID Fee Description Fee Permit Type Grou 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 / IBSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer CITY OF CUPERTINO REPIPE/SEWERIMAIN SERVICE CI O CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type IPRREPIPE 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 IBPFDCTURE Plumbing Fixture . P 1PGASRES Residential Gas Piping System 1-4 Outlets P 1BPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P I1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B Revised 6-16-08 0 • 0