08110103 CITY OF CUPERTINO ,� st ;#•+�a' �'7.
CTU
I DING DIVISION PERMIT CONTRr1�TORIATk'O$NIATIOI�F `- .
" m=.,amu a �?, �� �.��g
BUILDING ADDRESS: PERMIT NO.
1120 S.-OELLING RD CUPERTI
R'S NAME: PQNffT L4UE DATE
E: SA Ytti CONTROL N0.
ARCH rfECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
MAIN SEWER REPLACEMENT O O O O
u00 LICENSED CONTRACTOR'S DECLARATION Ib Description
i� 1 hereby alTimt WI Iwo licensed under Provisions of caper 9(am OesCTI mancus p
Ug viN Salon 7000)ofDivision 3of tic Bnsin=and Rofeumm Cade.aud my lice=u
n fenfartsa�erce Y9v
j Z LLicence Clvu Lit.• .
Do. Co."
WARCHITECT'S DECLARATIO
` 77 1 uMenuml mY PWas sail be used as public mcorN
;yU
e cep 3 Licensed Pmfessfons
OWNER-BUILDER DECLARATION
f I kreby anion that I am exempt from We Contrsctoes Liana Law for the
following..a.(Section 7031.3,Business and Professions Cade:Any city or county
3$ which=quime a Permit he crosmact,alta,imPham,dcmalW,a repsr any=atum
prim in its issuance.alw requires theapplicant for such Permit no file a signed statement
s< t k u Hee=d pat>vam m the pm.;.sam afore cammaora era=Uw(caPW 9 Sq.Ft. Floor Area Valuation
ss l-� (canmeacing with Section 70001 of Division Sof the Business and Profession Code)=
s
Was k u exempt therefrom and tic basis far the siugcd aemptiom.Any violation of
section 7031.3 by my applinnt for a permit subjects He applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5300).
❑1,uawryofdtepWµ y.mmyemploy=wiNwagesu Neualecompenudon,
hid Pr Hesirms ands:The Co tstues Ljdudmarttmaca rau(Sec.an a4.Bmbsu Required Inspections
Proand Nwfuilam Cade The reanuuml,Dame law dao cot apply tf rt ower of q 13
own enyloos builds provided emphases Hereon,and who dessuchwant himulfar for We hu
awnemploy=,ldinHalweltimpmsemenu ate nm year O emaBemtl for We.If.
buil a We building u Impmsmratg cold within ea year or completion.We oww-
eak). will have tic burden of Proving Nat k did net ndlo or impose fm purpose of
tele.).
1,as ow=af We poparty am cacluively comrac'ting pith licensed camrutms b
construct the project(sec.7044,Business and Pmfessiao Code:)The Comracmt's Li-
come law d=not apply m an of property who WildsorimPmw C-Moseemen,sod
IOM contracts for such ply to a hiN hunter cof ropers)licensed pursuant m es eantraaord
Lkcoe law.
❑Iamaemparader See ' .B&Pcfar Ntsmawn
1370Dan Dam a,53 —51 / 3
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pewtY of perjury arc of He fallowing lame s0oo:
ha.e mud will msmam a Certificate of Consent m self-inure fm Workces Compen- D
n,u provided fm by Section 3700 of the labor Cade,for the perfarreana of the
for which this permit is issued.
have e L will mile,far Warkeh Compensationthe
lourana,h¢qui=d by Semicon
of ae labs Code optic peRmmance of d work for which Nu permit is iuved.WorkeYs Compensation Iminance ansa and Policy number a=:
tamer. ?z-'rr, Policy No.: JAAA,7_?6-'7
CERTiFlCATE OF EXEMMON FROM WORKERS
COMPENSATION INSURANCE
(Thu orlon need nor kcompleted If tic permit ufmane hundred doBm(5100)
or less)
I certify that in No pMforra.of We work fm which this permlt is iaued.I until nm
employ any Aran in any miser=u to become subject to We Watters Campemadom
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
became subject m the Worker's Camp:nsation prevismu of Ute lathe Cade,you mass
O fonbwio comply with each Provisions m Nu mall all k damud motel
Z � CONSTRUCTION LENDING AGENCY
(-r Ihereby affirm Wt dart u•cootmctio lcndingageay for We performan¢of
aNe work far which this permit u issued(Sec.3097,Civ.C.) '
lLl Q LanticYs Name
7 z Lenders Address .
U C) 1 certify Nat 1 haw rad this application and sum L u We above information is
I,, E covets I ag=e at comply with all city and county ordioaras and sum laws altars to
.O building construction.and hereby auNarim representatives of this city to an=upon the
r[t7 move-mendowd popeny for impaction purposes
6. (We)agree to ave,indemnify and kap armless We City of Cupertino agsot
HTry liabilities.Judgments,emu and expemao which may he my way theme,against said Cy
U 2 in canaquermc of tic granOng of Hu permit
2. i,
!U.
Eby
COMPLY WITH ALL NON-POINT Issued by: Date Uh
LATI1 .
� /L;?6_'* Re-roofssigni deanDauHAZARLS DISCLOSURE Type of Roof
pplicant a fmmustore or a main hamMom material
deCupertino hapter 9.11.and dte Health and Safety
s3z(q± All roofs shall be inspected prior to any roofing material being installed.
pplicant mcupant ase Wipmcot a&A.which If a roof is installed without first obtaining an inspection,I agree to remove
Tit ir caumi. He Bay Area Air Quality Management all new materials for inspection.
District?
Ya u
1 have read We arallousmateriats tryuiremenu umlerCapecrii.95 of He Calif=-
mixHaJ"WeyCatlq Sad=BM3,25533a 25534.ImdcmvWHuif Ne building
does tet currently ave a l it It my mRommility 0 Mary We occupant of We
mgmiremunts IOM prorm wfa ccmlmuaof Ocmyancy. Signature of Applicant Date
"v
OwncwJN a�cm All roof coverings to be Class'%W'or better,
Da¢'
w Community Development
J 10300 Torre Avenue
Er Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
/12-0 S, D
OWNER'S NAME: PHONE # 7 — 3 2 YR
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36226008 . 00
DATE ISSUED. . . . . . . : 11/26/2008
RECEIPT # . . . . . . . . . : BS000006706
REFERENCE ID # . . . : 08110103
SITE ADDRESS . . . . . : 1120 S STELLING RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : OPAL LEMMER
ADDRESS . . . . . . . . . . : 1120 S STELLING RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : FRANK CARDIA
CONTRACTOR . . . . . . . : CARDIA, FRANK L LIC # 612
COMPANY . . . . . . . . . . : CUPERTINO PLUMBING
ADDRESS . . . . . . . . . . : 1300 DELL AVE STE C
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 253-0618
•
FEE 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
•
CITY OF CUPERTINO
lREPIPE/SEWER/MAIN SERVICE
CUPEIll PERMIT APPLICATION FORM
APN # �� xT�. Date:
Building Address: lJV
/ /2U
Owner's Name: Phone #:
op�l 57 — 3 Z 1/9
Contractor: Phone #: 25 3—CX,t 8
�Lf .p Fax #:
Contact: Phone#:
�TGYY�
Fax #:
Contractor License#: CooZ cjp j
Cupertino Business License#:
Job Description:
ML` {r\ 4�2W19! ra plc Cmont
Residential Commercial ❑
Valuation: ter d Q U
Project Size: Express fandard 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: Cl-
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
113PREPIPE 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
CITY OF CUPERTINO
(d" REPIPE/SEWER/MAIN SERVICE -
CUPEkTiNO 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
1PPERMITFEE 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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