12020105 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10691 HALE PL CONTRACTOR:CUPERTINO PLUMBING PERMIT NO: t2020105
OWNER'S NAME: SEREMETA ELENA AND DORIN TRUSTEE
134fl DELL AVE STE C DATE ISSUED:02/23!2012
CAMPBELL,CA 9SOOf3 PHONE NO:{408)253-06TH
OWNER'S PHONE: 4089739837
❑ LICENSED CONTRACTOR'S DECLAR TION gUILQINC; PERMIT INFO: BLDG , ELECT , PLUMB
License Class -- t.ic. MEC.H€� RESIDENTIAL COMMERCIAL
.(/ I pl`- Date ��
Contractor �� JOB DESCRIP'T'ION:COPPER RE-PIPE AND REPLACE WATER MAIN
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that ray 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 Valuation:$5000
performance of the work for which this permit is issued. Sq,Ft Floor Area:
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:32640009.10691 Occupancy Type:
Permit is issued.
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indetanifv and keep harmless the City of Cupertino against liabilities.judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may,accrue against said City in consequence of the <
granting of this permit. Ad ally',the phcant understands and will comply
with all non-point e ulat' he Cupertino Municipal Code,Section Issued�_._ ---�--- -
9.13. <-
Signature
--Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION installed
roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without.first obtaining all inspection,I agree to remove all neve materials for
I hereby aff'ir'm that I am exempt from the C'ontractor's License Law for one of inspection.
the following two reasons: Date:
I,as owner of the property,or my employees with wages as their sale compensation, Signature of Applicant:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct tine project(Sec.7044,Business&Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
declarations: I have read the hazardous materials requirements under Chapter 695 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Cade,for the Safety complrCode,ance with
25532(x)should Irtino nto a oral ehandlethazardous er 9.12 and
ateriallNr&
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,nt_s provided for by contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Permit is issued. Health&Safety Code,Se 5505,25533,and 25534.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so:>s to become subject to tile a
e Worker's er or author' to
Compensation laws of California. if,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked.
le I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep hannless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand ray plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature
Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
C U P E RT I N O Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: 4 1 2 PERMIT#
OWNER'S NAME: ftv�ti o r,' n 5� nc�f't--- PHONE# 9 Q
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 ItLLL C �RS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. SUBONw:=
I am not using any subcontractors:
Date
Please check applicable subcontractors and complete the following information:
s/ 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
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32640009. 10691
DATE ISSUED. . . . . . . : 02/23,/2012
RECEIPT #. . . . . . . . . BS000016093
REFERENCE ID # . . . : 12020105
SITE ADDRESS . . . . . : 10691 HALE PL
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER SEREMETA ELENA AND DORIN TRUST
ADDRESS . . . . . . . . . . : 10691 HALE PL
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
---------- ------------- ---------- ---------- ---------- ---------- ----------
1ADMIN HOURS 1 .00 41. 00 0 .00 41.00 0 .00
1BCBSC VALUATION 5, 000 .00 1 . 00 0 .00 1 .00 0. 00
1BPWSVCS WATER SERVICE 1. 00 22 .00 0 . 00 22 .00 0 . 00
1BSEISMICR VALUATION 5, 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
1TRAVDOC FLAT RATE 1.00 44 . 00 0 . 00 44 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT : 164 . 50 0 . 00 164 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 164 .50 VISA
---------------
TOTAL RECEIPT 164 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
DATE: 02/23/2012 REVIEWED BY: bobs.
ADDRESS: 10691 hale pl.
APN: BP#: VALUATION: $5,000
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition I Repair
PRIMARYPENTAItIATION 1 RPRP
USE: SFD or Duplex PERMIT TYPE:
WORK copper re-pipe and replace water main.
SCOPE
APPLIANCE 1 EQUIP TYPE FEE ID QTY UNITS BP FEES
Re-Pipe Interior 1PRREPIPE 1 # $12
Water Service 1BPWsvcs 1 # $22
TOTALS: $34'00
Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: IPPERMIT
E3-L- Other Plumb Insp. OA hrs $44.00
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the relin ina info available and are onl an estimate. Contact the De t or addn 7 info.
FEE ITEMS % 'aa:.s.r.,=,'{,_� 1,-t'�_3 � 1 1: 11
FEE QTY/FEE MISC ITEMS
PNIE Plan Check: $0.00
PME Unit Fee: $34.00
PME Permit Fee: $44.00
ILI-
Administrative Fee: ]ADMIN $41.00
Work Without Permit? 0 Yes (Q No $0.00
Travel Documentation Fee: ITRA VDOC $44.00
; -§pry,,, �L� ,,_i ��;,: 1BSEISMICR $0.50 Select an Administrative Item
_r-_
IBCBSC $1.00
_ T SUBTOTALS: $164.50 $0.00 TOTAL FEE: $164.50
Revised: 1/19/2012
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 M '
(408)777-3228• FAX(408)777-3333• buildincl(acupertino.org
sc
CUPERTINO
PLUMBING ❑MECHANICAL- ❑ELECTRICAL- ❑MISCELLANEOUS
DRESS � j _,�� J�m
PRO ( U•- �-FiPHONE' .. ak3 E-MAIL
OWNE�Ny4MEC �1 J . 7rfCITY,STATE,ZIP STREET ADDRESSCONTACT NAME PHONE 1 E-MAIL► dk[ U 14 )CIIY,STATE, ZIP
STREET ADDRESS
❑OgrNER ❑ OWNER-HUII.DER ❑ OWNER AGENT
❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
j�r
LICi�G' LICENSE TYPE HUS.LIC#
[CONTANY'kAME
01�NA� �� h f
E-MAIL
FAX
s ADDRE CITY.STATE, vA -2 5 3 o�o
LICENSE NUMBER /'�� BUS.LIC M
ARCHITEC/ENGINEER NAME lJ
E-MAIL FAX
COMPANY NAME'
CITY,STATE,ZIP PHONE
STREET ADDRESS
USE OF -or DUPLEX ❑ MULTI-FAMILY PR07ECT IN wmnLAND ❑ YES PROTECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑CDMMERCIAL
URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO IICHLERHOME? ❑NO
DESCRIPTION OF WORK M
U/\ \ �---- RECEIVED BY:
TOTAL VALUATION: G✓� L J U
By my signature below,I certify to each of the fallowing 77
I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct ave escription of Work and verify it is accurate. I agree to corrrply wi$r'all applicable local
ze ves of Cupertino to enter the above-identified pro erty for inspectson pudposes.
ordinances and state laws relati}g to ldulg j�• �. s 2 2,
G� •' Date:
Signature of Applicant/Agent
S WkORMA 11UN REQUII�ED OFFICE USE ONLY
L� OVER-THE-COUNTER
❑ EXPRESS
Y
w
,. ❑ STANDARD
U
< ❑ LARGE
❑ MAJOR
A•IE'pmscApp 2011.doc revised 06/21/11