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12010008 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10447 VISTA KNOLL BLVD CONTRACTOR:CUPERTINO PLUMBING PERMIT NO: 12010008 OWNER'S NAME: CHEN JIM J AND JILLIAN K 1300 DELL AVE STE C DATE ISSUED:01/03/2012 O""PER'S PHONE: 4087288701 CAMPBELL,CA 95008 PHONE NO:(408)253-0618 d LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class _ 1(. Lic.# 't C) ' MECH RESIDENTIAL COMMERCIAL Contractorl— 1'V Date 3 - ) I herebyaffirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-PIPE AND WATER HEATER REPLACEMENT p p **SEE NOTES** (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$4000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:32613032.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue ag!!pt said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionall ant understands and will comply with all -point source re I Cupertino Municipal Code,Section 9.18 / Issued by: Date://' — f Signature Date � — / r OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owner or zed a become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of Aork's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION i ng of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32613032 . 00 DATE ISSUED. . . . . . . : 01/03/2012 RECEIPT #. . . . . . . . . BS000015643 REFERENCE ID # . . . : 12010008 SITE ADDRESS 10447 VISTA KNOLL BLVD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER CHEN JIM J AND JILLIAN K ADDRESS 10447 VISTA KNOLL BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : FRANK L 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 ---------- ------------- ---------- ---------- ---------- ---------- ---- -ADMIN HOURS 1.00 41.00 0. 00 41.00 0.00 1BCBSC VALUATION 4, 000 .00 1. 00 0 . 00 1. 00 0.00 1BSEISMICR VALUATION 4, 000. 00 0.50 0. 00 0 .50 0. 00 1PPERMITFE FLAT RATE 1.00 44 . 00 0.00 44 .00 0.00 1PRREPIPE NO OF FIXTURE 1.00 12. 00 0. 00 12 . 00 0. 00 1PRWHEATR UNITS 1 .00 26 . 00 0.00 26 .00 0 .00 1TRAVDOC FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 168. 50 0. 00 168 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 168 .50 VISA --------------- TOTAL RECEIPT 168.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- -------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building(a�cupertino.org MISC PLUMBING MECHANICAL ❑ELECTRICAL [:]MISCELLANEOUS PROJECT ADDRESS ' 1 S�y ^� �I v� APN# ` �j 2. OWNER N ] r� vt ,I f HONE I E-MAII- STREET ADDRESS Qom` r 6 CITY, STATE,ZIP FAX CONTACT NAME PHONE_ _-34/ fG,1V- T STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT m CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT COINLIPMACTOR NAME ` LICENSE NUMBER LICENSE E BUS.L1C# CO NAME E-MAIL FAX STREET ADD SS CITY,STATE,ZIP Sic �— PHONE -2S 3 --(XI I ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF ( FD or DUPLEX ❑ MULTI-FAMILY PROJECT W WILDLAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN El YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: C D r— RECEIVED BY: f 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 ILhave provided is correct. read escription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatinil�dinn on represents; s of Cupertino to enter the above-ide led property for inspection pufposes. Signature of Applicant/Agent: a-S Date: e#4 `� 12 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY HE-COUNTER c ❑ EXPRESS Y U 2 ❑ STANDARD U ❑ LARGE c ❑ MAJOR MBPMiscApp 2011.doc revised 06/21/11 Building Department City Of Cupertino Lo 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 ,U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST 2 &�6 ,jc- JOB ADDRESS: /D0/7 PERMIT# `-Z 7S - CS5 70 OWNER'S NAME: PHONE# 41C% GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 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 Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date