08120109 CITY OF CUPERTINO ,•+ 'Nkiftt �' a�- ria +'` '�''`-q
BUILDING DIVISION PERMIT CONTRACTQRIATF,ORMATIO.N'
BUILDING ADDRESS: PERMrr NO.
1174 BUBB RD CUPERTI
OWNER'S NAME: PERNUT ISSUE DATE
NE: A e 8 CONTROL 10.
IF (408) 253-0618
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
00c LICENSED CONDUCTOR'S DECLARATION Job Description
V C 1 hereby serum that 1 am licensed under provisions of Chapter 9(commencing P
b with Section 7")of Diviaion lofdm Bromessand Profession,Colt,W my license is
; F in full forte andel S 4v COPPER RE-PIPE
j,�Z License Class Lie.N
DElZIr
e 7W ARCHITECTSS DECLARATI al
e W U I understand my plans shalll a trod v public recaNs
n
s O LicensedRvfcstioal
3 OWNER-BUILDER DECLARATION
a�<N 1 hereby sMo.that I am exempt from the Contravenes License law far the
no following on.(Section 7031.5,Business and Prolamines Code:Any city or county
a ff which Inquires a permit m canstrvcC alter,improve,demolish,Or mpti,any structure
_ prior b its issuance,also requires the applicant For such permit to file a signed statement
ii that he is licensed prnmenttoBoprovisions oftheCentimeter's LicenuLaw Charter 9 Sq.Ft. Floor Area Valuation
yt-o (commencing with Section 7")of Division 7 of be Busineseand Profession Code)or
y 3
has be u esempt thererrom and the basis for dee alleged emmption.Any violation of S5000
Secdon 70.113 by any applicant for a permit subjccu the applicant o a civil penalty or APN Number Occupancy Type
not¢ort than five hundred dollars ISM
❑I,asowrerofNepmperty.ormyemplay=Wiffi agesudte mkvmnpevadan, 36206028 . 00
will dothework.soddee es Camsanms Useedorawdo for sate(Sec.M an ow.
W Rywho lu Code:Tk Cemnome, cad w1b.law dao or apply lf an mwxr car Required Inspections
pmpenywhabuildsorimpavesch improvements
who are nsucbwmk himselfar forsal his
awn employees,er.the
Nm such impmsold wi are not intended m leemA formate If.
builder.Ne building orimprovement 4soldwithinoneyeti or completion,citeowner-
builder will have be burden of Proving Nu M did not build or improve for purpose of
ole.).
❑I.u owner of the property,me exclusiWIY contracting wide licensed aI==to
comuuet the Praises(s¢.7044,Business and Professions Code:)The Caruaemts Li-
cove law does oat apply us an owner of property who Wilds or improv decreer,and.
who contracts for such patens with aconuacmn(s)licensed potshard m dee Comrsamrs
Live law.
El IameumpunderSee ,B&PCror Ndrmason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby slims under penalty of perjury one of the following decluedov:
1 have and will maintain a Certificate of Covent m=K--ivum for Workces Compere
,on,as provided for by Section 37W of dee labor Cade,for the perfarmena of the
work for whiapererot is imue"L
ban tab will maintain Workers Compensation Insurance,as required by Sccdon -
37(10 of can lather Code,for the performance or Ne work foowhich this permit u issued.
My Works/ ,.firm btsurana artier and Policy number am:
K WS' 8
Cartier.�,• +v+� eoliey No, as
CERTIFICATE OF COMPENSATION
EXEMPTION FROM E S'
COMPENSATIONINSURANCE ,
This acnlan need not he completed if the Permit is forou hundred dollen(SIM)
or less.)
I entire the,in the orfonmume of Ne work for which this Permit is issued.I shell nut
employ any person in any mmurm as be become subject to the Workers'Compn,a0on
Laws of Cahromix.Date
Applicant
NOTICE TO APPLICAT:If.after making Nu Ceniriale of Exemption,you should
become subject m the Workces Compensation provisions of the Lahor Code.you most
.Jz forthwit comply with such provision or this pearit shall M deemed revoked.
zi O CONSTRUCTION LENDING AGENCY
[-�.N. 1 hereby alErm that there is a construction lending agency fns Ne Performance of
CL 1 the work for which tho permit u issued(Sea 7097,Civ.C.)
GLender's Namc
z Lender.Address
t.)0 1 modify that I have read this application and sum Nu the shove inforreadun u
cmmmc I since m oomplY and'all city and county ordinances and soon laws relating m
.0 Wilding consuucore,and hereby aushor a representatives or Nu city be enter ups the
I17 aten-mationcd popery for inspection pmpomx
1 (We)agree to sate,indemnify and loop hmmteu dee City of Cupertino against /117
,.yy liabilities judgments,costs and exposes which may in any way¢crue against mid City
V z in consequence of the graining of omit.
^
APPLICANT=O"T",UND � iLL COMPLY WITH ALL NON-POINT Issued by: Date
5 R AJTON —(6 -
/6 _C) Re-roofs
Si SfAppli a of /// ! I Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm appit.,or rum.building eavpantsmre or handle huallov ro mrial
as denra d by the Cu Irmo Municipal Cade,pmpmr 9.12.and the Health and Safety
Coal Scctien uslz(n±
❑Yes BNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it banolous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
uin7
❑Yes &f.--
I have read the hasandov mueruls roclemments under Chapter 6.95 ofdee Califear-
nu Haiti&SafctyCedc,Seeders 35505.35333 and 35534.i understand tuttrust,building
does not cmendy have a meant.that it u my responsibility he notify tho occupant of the
mttimments which rpnnbe mel..tdmmarmaa acnm aroaapancy. J Signature of Applicant Date
Owner tar auNasnitl i Dam
All roof coverings to be Class'1W'or better
CITY OF CUPERTINO
• 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36206028 . 00
DATE ISSUED. . . . . . . : 12/16/2008
RECEIPT # . . . . . . . . . : BS000006835
REFERENCE ID # . . . : 08120109
SITE ADDRESS . . . . . : 1174 BUBB RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : TAN NGUYEN
ADDRESS . . . . . . . . . . : 1174 BUBB RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4961
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
------------ --- ---------- ---- ---- ---------
1BPWATER UNIT 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1BSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 .00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRREPIPE NO OF FIXTURE 11 . 00 112 . 20 0 . 00 112 .20 0 . 00
ITRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
-------- ---- ---- ----------
TOTAL PERMIT 235 . 07 0 . 00 235 . 07 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ----------- -
CREDIT CARD 235 . 07 VISA
---------------
TOTAL RECEIPT 235 . 07
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 507 FINAL PLUMBING
•
0S/0 v/ 0
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEIfTIN0 PERMIT APPLICATION FORM
APN# 2 / a U (e C) p.k , J J Date:
Building Address:
0 9,6b Ze ,
Owner's Name: Phone #: e/2- ,5 _ 9/o8
�n t�
Contractor: U Phone #: 5 3 p C� 18
C— Y--, (Cino P� ��„ �� Fax #:
Contact: Phone #: '
Fax #:
Contractor License#:
Cupertino Business License#:
Job Description:
C� CPN �-P'�-�--
Residential �� Commercial ❑
Valuation:' UUC�
Project Size: Express Standard ❑ 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
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
CITY OF CUPERTINO
` 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
•