12040130 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21074 IAVINA CT CONTRACTOR:PPYH I.LC PERNIrr NO: 12040130
OWNER'S NAME: PPYIT LLC 21074 LAVINA CT DATE ISMJED:04/252012
OWNER'S PHONE: 4082554013 CUPERTINO,CA 95014 PI ION I.NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q
M ECH r RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALLATION OF ONE(I)SINK AND WATER CLOSET IN
(commencing with Section 7000)of Division 3 of the Business&Professions EXISTING GARAGE APPROVED WITH APROVED ROUGI IIID IN
Code and that my license is in full force and effect. PLUMBING UNDER PERMIT'RP43813
1 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
Section 3700 of the Labor Code,for the performance of the work for which this Sq.FI Floor Arca: Valualion:8500
permit is issued.
APPLICANT CERTIFICATION APN Number:32608027.00 Occupancy Type:
I certify that I have read(his application and state that the above information is
cored. I agree to comply with all city and county ordinances and stale laws relating
to building construction,mid hereby authorim representatives of this city to enter
upon the above mentioned properlyfor inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnifyand keep itich harmless the cru ofainsts id against consequence
enceofthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may acerae against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Igo DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Cade,Section
9.18. /
Issued by: Z f,)i�/-71 Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm(hat I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material berg installed If a roof is
the following two reasons: installed without first obtaining an 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,mid the structure is not intended or offered for sale(Sec7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). AL1,ROOF COVERINGS TO RE CLASS"A"OR BETTER
1 hereby affirm under penally of perjury one of the following three
declarations: IIA'J.,ARDOIIS MATERIALS DISCLOSURE
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 hmuirdous materials requirements under Chapter 6.95 of the
performance of the work for which(his permit is issued. California Health&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of(he Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hrvardous air
permit is issued. contaminants as defined by the Bey Area Air Quality Management District I will
I certify that in the performance of the work forwhich this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to became subject to the Workers Ileallh&Safety Code.Sections 25505,25533,and 25534.
Compensation lusys of Califomia. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must neer ort authorindiagent: r ` T jC Z
forthwith comply with such provisions or this permit shall be deemed revoked. ,� �t�' 5=�� --" Date: -
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and stale that the above information is I hereby alliin that there is a construction lending agency for(he perl'ormance of work's
correct. I agree to comply with all city and county ordinances and sale 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 Iiabilities,judgmems, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting offlus permit.Additionally,the applicant understands and will comply ARCIIITECT'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 ,•..}�� S j✓ �s� Date L LZ"A•`U� l Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32608027. 00
DATE ISSUED. . . . . . . : 04/25/2012
RECEIPT #. . . . . . . . . : BS000016617
REFERENCE ID # . . . : 12040130
SITE ADDRESS . . . . . : 21074 LAVINA CT
SUBDIVISION . . . . . . .
CITY . . . . : . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PPYH LLC
ADDRESS . . . . . . . . . . : 21074 LAVINA CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : PAUL S POON
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : PPYH LLC
ADDRESS . . . . . . . . . . : 21074 LAVINA CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
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 500 .00 1.00 0 .00 1 . 00 0.00
1BPFIXTURE NO OF FIXTURE 2.00 18 .00 0. 00 18.00 0 .00
1BSEISMICR VALUATION 500 .00 0.50 0. 00 0.50 0.00
1PPERMITFE FLAT RATE 1.00 44 . 00 0. 00 44 .00 0.00
1TRAVDOC FLAT RATE 1.00 44 . 00 0. 00 44 .00 0. 00
---------- ---- ---- ----------
TOTAL PERMIT 148. 50 0. 00 148 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 148.50 VISA
---------------
TOTAL RECEIPT 148. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ---------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING 512 FINAL HANDI-CAP
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 21074 Lavina Ct DATE: 04/25/2012 7REVIEWED BY: Sean
APN: BP#: 'VALUATION: $500
PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPFIX
USE: PERMIT TYPE:
WORK Installation of 1 sink and water closet in existinggarage approved with approved roughed in lumbin
SCOPE under permit BP43813.
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixture or Trap 1BPFIXTURE 2 # $18
TOTALS: $18.00 -
1-1rrh. Man C'hrrk Plumb. Plan Check 0.0 hrs $0.00 1_h:<:. Won Chcr:!
11cch.I'.rmi!Fee: Plumb. Permit Fee: IPPERMIT IihC. Pe)mil 1•e":
.htr,•/i. h!sl. Other Plumb Insp. 0.0 hrs $44.00 Ulher EhC.Irsp.
insp.Iee Plumb. Imp. Fee @ler. he'P. Ve"
NOTE: This estimate does not inelude fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on.The prefimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Pee Resohainn 11-053 1(( 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fed:
Suppl. Pc. FVL
PME Plan Check: $0.00
Pvo mit Fec.
Suppl. Insp Fe"
PME Unit Fee: $18.00
PME Permit Fee: $44.00
Crnlshvction Tae:
Administrative Fee: IADM11V $41.00
Work Without Permit? Yes (E) No $0.00
Arlvanccd Plauni!r; Fees:
Travel Documentation Fee: ITRA VDOC $44.00
Strong Motion Fee IBSEISMICR $0.50 Select an Administrative Item
Olda Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $148.50 $0.001 TOTAL FEk: $148.50
Revised: 04/01/2012
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE"CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228v FAX(408)777-3333• buildinora)Cuoertino.ora
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS 7 �� y APN 326 - O?, o2 -7 BP#
IG ,y LAV;
9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service,the United States,Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am✓the party legally and financially responsible for proposed construction activity at the site address listed above.
11 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions,deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be Issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's si na
Property Owner's Signature: i/ CY/L Date: 'R,L Z y
------------ :-- ------- ----- ----- - ---- ------------W-c------- --------- ------------a ------ ----------- ------------- ----
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal respynsibttity, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign,and file the doc raetf a necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address: ,-,9 1 U-7 L AV LV�J Dr'%1:71,V LeA y J u�
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penal erjury that I am the property owner for the address listed above and I personally filled out the
above information certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification a ptable to the city maybe required to be presented when the permit is issued to verify the property owner's
signatur
Property Owner's Signatuie: Date: /-I-1-21C L P 0`''
0wncP-Bui1dcrFovn1 2010.doc revised 04114110
TOOT NG .. . .
APR252012
I ,
10
CUPERTINO
i = ' xl jt; _1_V6 J ne Department
,K i.. APR 15 2012
REVIEWED FOR CODE COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT Revi
BUILDING DIVISION-CUPERTINO ewed By. -
APPROVED Y
This set of plans and specifications MUST be kept at the ' OFFICE ®P
j
job site during construction. It is unlawful to make any t N
changes or alterations on same,or to deviate i I
therefrom,without approval from the Building Official.
The stamping of this plan and specifications SHALL NOT
j be held to permit or to be an approval of the violation
i of any provisions of any City
//Ordinance or State Law. CjA i� _ .�
A
BY
DA i,1t
j DATE RFool
i PERMIT NO. -
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GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 M I A
CUPERTINO (408)777-3228• FAX(408)777-3333• bUIldingCcDcu0ertn0.Or0 (v'
PLUIrIDING ❑MFCRAMCAL ❑ELECTRICAL ❑NGsa TTANFDUS
FRCJELTADDRFSS '2/G'7q LAVlvr� CT, C'v-pLRT/u�. (/�-JSUI�{ AFNa Z� — O ()s�7
7
OWNERNAME1 Awl_ �7JJ AJ PFiOidF�a+� ).'1sr' 4013
s-t=ADDRESS .,214 iq 2-Av.,.v LI (T, QP( SLATE,� r FAX
CONTACT NAME I�It 7 C I V(1,l/ J L U E-MAI
y 7 `F e') a_S 4 !
TrIUISTADDRESSCITY,STATE IIP FAX
s 1 ' A3 o✓.-.
AOWNER ❑ OwNER-RUIIDER . ❑ OWNERACENr ❑ coNTRAcmR ❑LDNrRACtoRAGElT ❑ ARCHTECT ❑ENGINEER ❑ DEVELOPER ❑ rFNAxr
CONTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS.LICA
COMPANY NAME E-MAI FAX
STREET ADDRESS QTY.STATE ZIP PRONE
ARCTITECTIENGINEER NAME LICENSE NUMBER BUS.LIC p
COMPANY NAME' E-MAI FAX
STREET ADDRESS CITY,STATE ZIP PHONE
USE OF STD.OUPLEX ❑ MO FAKILY PRDEcTNwv.DL xD ❑ YES PROJECTIN ❑YEs IS THE BLDG AN ❑YES
BUDDING: tjwMA ctm. URBANDITERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOMET [3 NO
DESCRIT71ON OF WORK
To /A/b SW ' r4 7 - -D - /10/&--j) 1'11 : v =
TOTAL VALUATION: RECETVEDBY:
By my signature below,I certify to each of the follawiag. I am the property owner or anthorized agent m act on the ptoperty owner's behalf. I have read this
application and the infosmatoo I have provided is correct j have read the Description of work and verify it is acuate. I agree to comply with all applicable local
ordmarices and state laws relating V 6.Wing co tion. r authorize representatives of Cupertiao to enter the above-idcatified property for inspection pu@oses.
J� / , ,
Sipsanne ofAppficant/Agent L (Y� I,o i Date: ,fit L o� -.2
SUPPLEMENTAL INFORMATION REQUaM OFFICE USE ONLY
v OVER-THE-COUNTER
Z
>: ❑ ttaPRsss
m
❑ STANDARD
u
3 ❑ 1ARGE
❑ MAJOR
MPPMac4pp_2011.doc revised 06/21111