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12020117 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10267 VISTA KNOLL BLVD CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 12020117 OWNER'S NAME: AVERY&KAY CHING 1639 POMONA AVE DATE ISSUED:02/27/2012 OWNER'S PHONE: $474454846 SAN.JOSE,CA 95110 PHONE NO:(408)295-3911 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFU: BLDG � ELECT � PLUMB � License Class r Lic.# D p / T MECH ;.... RESIDENTIAL C: � OMMERCIAL , Z Contractor dP f ate Z /� I hereby affirm(hit i am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER LINE WITH"L"GRADE COPPER FROM (commencing with Section 7000)of Division 3 of the Business&Professions THE METER LINE TO HOUSE 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 37100 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 Section 3700 of the Labor Code,t6r the performance of the work for which this Sq.Ft Floor Area: Valuation:$2500 permit is issued. APPLICANT CERTIFICATION APN Number:32613127.00 Occupancy Type: 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 upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnity and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAB'S OF PERMIT ISSUANCE OR granting of this permit. Additionally, t understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations rtino Municipal Code,Section SignatureDate Z 14 P— Ile— T.— Issued by• Date: ❑ OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the C'ontractor's License Law for one of All roofs shall be inspected prior to any roofing material beiig installed.If a roof is the following two reasons: installed without first obtaining air inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec,7044,Business tic Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this per€uit is issued. California Health&Safety Code,Sections 25505,25.533,and 2.5534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with tI€e Cupertino Municipal Code,Chapter 9.1.2 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this additionally,should I rise equipment or devices which emit hazardous air Permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the pert6rnrance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ arty person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I K e become subject to the Worker's Compensation provisions ofthe Labor Code,I must Owner or au �� _ z �11leL_ forthwith comply with such provisions or(his.s permit shall be deemed revoked. �s�_ Date: CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby af I certify that I have read this application and state that the above information is firm that there is a construction lending agency for the performance of work`s correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ,ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . 32613127 .00 DATE ISSUED. . . . . . . ; 02/27/2012 RECEIPT #. . . . . . . . . BS000016116 REFERENCE ID # . . . 12020117 SITE ADDRESS . . . . . 10267 VISTA KNOLL BLVD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . AVERY & KAY CHING ADDRESS . . . . . . . . . . 10267 VISTA KNOLL BLVD CITY/STATE/ZIP . . . CUPERTINO, CA 95014 RECEIVED FROM . . . . WILLIAM D DEPMSTER CONTRACTOR . . . . . . . WILLIAM DEMPSTER LIC # 31263 COMPANY . . . . . . . . . . DEMPSTER PLUMBING ADDRESS . . . . . . . . . . 1639 POMONA AVE CITY/STATE/ZIP . . . SAN JOSE, CA 95110 TELEPHONE . . . . . . . . (408) 295-3911 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 2, 500 .00 1.00 0 . 00 1.00 0 .00 1BSEISMICR VALUATION 2, 500 .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 142 . 50 0. 00 142 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 142 .50 VISA --------------- TOTAL RECEIPT 142 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 10257 vista knoll DATE: REVIEWED BY: bobs. APN: I BP#: *VALUATION: $2,5fl0 R-PEW�,HT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPRP USE: P I PERMIT TYPE: WORK re lace water line to water service. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Re-Pipe Interior 1PRREPIPE 1 # $12 TOTALS: $12.00 Plumb. Plan=e& 0_1 hrs $0.00 Plumb.Permit Fee: IPPERMIT LjOther Plumb Insp. O.fl hrs $44.00 - NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public{forks,Fire,Sanitary Sewer District,School District,etc. . These.Les are based on the relimina information available and are onlp an estimate. Contact the De t or addn7 info. FEE ITEMS (Fee Resolution 11-053 Eff. 7!1;'11) FEE QTY/FEF, MISC ITEMS EJ PME Plan Check: $0.00 PME Unit Fee: $12.00 PME Permit Fee: $44.00 EJ Administrative Fee: LIMWN $41.00 Work Without Permit? 0 Yes d No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stcls Commission Fee: IBCBSC $1.00 SUBTOTALS: $142.50 $0.00 TOTAL FEE: $142.50 Revised: 1/19/2012 Building Department City Of Cupertino Is 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: k) `5 A, PERMIT# OWNER'S NAME: PHONE# d Sri 77 GENERAL CONTRACTOR: c ��•+ 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 SUBCO T ORS AVE OBTAINED A CITY OF CUP7NO 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 ;0-� GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Lo (408)777-3228• FAX(408)777-3333• building4cupertin0.org misc CUPERTINO O PLUNMING ❑NEMAMLCAL ❑ELECTRICAL. ❑MIS LLANBCUS PROJECT ADDRESS1 C l L 612 S�L` k,, / % APN# 2--1 OWNER NAME Vc'_,, / L 4t PHONFy. �t- y --MAIL STREET ADDRESS (' CITY,STATE, GJ��/-/ FAX tGZ�_'2 i) Sri µv �. 16-,-) .- -'4 e-, �4t !i J' CONTACT NAME ` 1 t PHONE S"Y1 7 1 E-MAIL STREET ADDRESS: �• STATF,— / !!(j FAX ! 7 Q.•-re..:;pct V �7�..1 a.(C G._.y� �1.� ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT L CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHr cT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMELICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME� �/� FAX `JC�M c � �`tfrri�' s•«. �.�Ty4G-�� .�.,s-T�,•/'a;.=+t1s .-c�."t STREET ADDRESS f i 'G /)GG v Ayr :t L J / C ATE z p-- // �?S-/i G PH��) S� ARCHI=CTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME/?. ❑NO DESCR=ON OF WORK ( -{e y- ;'v Cc (a>, •�–� `� ,/ YC CY C--- _ v rte. .-�. e- 4-cr v /c c i c�c TOTAL VALUATION: �� RECEIVED BY: 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 I have provided is correct.�e� of Work and verify it is accurate. I agree to comply witty all applicable local ordinances and state laws relating to building s ti of Cupertino to enter the above-Id tified petty for inspection pudposes. Signature of Appacant/Agent: Date: Z l L--7( / SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER ❑ EXPRESS x U W ❑ STANDARD U ❑ LARGE a F13 MAJOR MEPMIscApp 2011.doc revised 06121/11