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12050036 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20709 GARDEN MANOR CT CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 12050036 OWNER'S NAME: IIEMADRI ANANTA 1639 POMONA AVE DATE ISSUED:05/03/2012 OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)295-3911 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El CO%IMERC1ALU License Class 1 � Lic.4 �0 REPLACE WATER SERVICE FROM METER TO HOUSE W/ �� }k � / • /Z Contractor -'� ��+�b>(ie S 3 TYPE"L" COPPER PIPING 1 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 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 whichthis permit is issued. Sq.F1 Floor Area: Valuation:$200 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work"Pr c4'Dli)s APN Number:36230075.00 Occupancy Type: permit is issued. , APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYf F M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, , costs,and expenses which may accrue against said City in consequence of the 7�/granting of this pemmil. Additionally, applicant understands and will comply Issued by: UCG Date: with all non-point source regulati pert eCupertino Municipal Code,Section RF.-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material berg installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. 13OWNER-BIIII,DF.R DECLARATION 1 hereby affirm That 1 am exempt from the Contractor's License Lew for one of Signature of Applicant Date the following two reasons: ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER 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, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSLRF, construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California health&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the declarations: Health&Safely Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Ouality Management District performance of the work for which this permit is issued. will maintain compliance with the Cupertino Man' I Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safely Code,Sections 25505,25 ,and 5534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, Owner or authorized agent* Date: I certify that in the performance of the work for which this permit is issued,I shall not employ any person in my manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCN' become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby a(fimh that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is cored. I agree to comply with all cityand 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Dale CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION 172 ADDRESS: 20709 Garden Manor Ct DATE: 0 5/0 31201 2 REVIEWED BY: Sean APN: BP#: 'VALUATION: 1$2,000 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Water Service PRIMARY Residential PENTAMATION 1CPWS USE: PERMIT TYPE: WORK a lace the water service from the meter to the house with type "L" copper piping. SCOPE APPLIANCE/EQUIP TYPE FEE ID BP FEES Water Service Unit Fee: 1BPWSVCS $22 —t-7 11-b 1'lun I I", 4 I'lunvh. flan C'hC,'h li h'e. 11"') Cn,iif 11.•cL. I'.-nr18 Fer, Plumb. Permit Fee: IPPERMIT Fl," P,nwir I (ldrcr' llc,ii_ ln.rp (khvr I'Imnh Imp. Li $44A0 ()//w' /:/c" l.np. ET IlrJr. /u p. Fe : Plun�L, loop. Fe._ /Clrr_Lr,p. LS.,.- NOTE: This estimate does not includejees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact lite Det or arlrin'l info. FEE ITEMS (Fcc Resolution /1-053 F#' 711111) FEE QTY/FEE MISC ITEMS I'lon (.hair I ,,,, lIppl. I'('1 b,r l'lr uu h_;;4.1rch.;Elcc l'rnnil SIfpjd heal, PME Unit Fee: $22.00 PME Permit Fee: $44.00 C'on,e/1111lion T(1. ,1,11N niam,ni " F("C: Work Without Permit? O Yes (F) No $0.00 ,I droucrd l'l,nulin_ Fdca.- /'rw c/ 1)ul n17wWoliu11 FCCS: S'nr,n,; :I/o"I'm k'ec: Select an Administrative Item 131(IC Slds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $67.00 $0.00 TOTAL FEE: $67.00 Revised: 04/01/2012 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO. CA 950143255 I CUPERTINO,�� (408)TR-3228•FAX(408)777-3333• buildinolalcuoertino.ory (� �j��j /lD sc EIPLUMBING MECHANICAL m T7C CALL E MISCELLANEOUS 12-D50` ` FAO.IECTADDRESS 26-.p 1 �,�elf� QnoN L I AN Z v O OWNENAME ` FXONE f.�b 3 EWa STRWr ADDREM G CCCY. 7' FAX CONTACT NAME �L\\ PHGNVoSS9� E-MAIL L'O,t c (//1. /✓n./J/ ,Ce" rtsEffTT ADOneeR (��`! Y'e„+�r,N ��C .siAtFy_� .� �L ��l/ O FAX eeoy c9-� l/ ❑OWNER ❑ DwNE-aw.nE . ❑ OWNER AGENT �cma. ❑CONTRACTOR AGENT ❑ ARammcr ❑wOwmt ❑ DEVELOPER ❑ rzNmr CONTRACTOR NAME f1CFNSE NUAIDERroJS/t^�j [icemi n-3 ) BUS.LIC#( COMPANYNAME T� !�l/V�LN+JI I /1 1 2MAB./•�2'S.-I(JCv 'a lJrs Cr_ FAX'V0 2&:3 STREETADORE59�/ ` � tCa m'LY l4 �LOu ��,.STCApJCri�C TGSC PHOT@p - '� -)"1 . ARCIDTEC IENGTNEFR NAME LICENSE NUMBER J BUS.INC A O COMPANY NAMEE-MAIL FAX STRIEEr ADDRESS CITY,STATE,ZDF FHONE USE OF DUPLEX ❑ MIB.TwAMRY PROIERIN W1LOf..WO ❑ YES PROJECT IN ❑YES ISTRBBLOGAN ❑YFS BUILDING: ❑WM.S¢RaAf. URBAN INTERFACE AREA NO FLOOD Z_O}N..E(� � NO OC�H[LE0.HO'MF/! �T10 DESCRIPTION OF WORK R lC`Le- �^-+4.l L.G' �P�1'V 4 C TJb M •� bNe�U' /-O ` e /Ions e n e L GA e. TOTAL VALUATION: 20c)40 2' RECEIVED BY: ^/ By my signature below,I certify to each of the fallowing'. I a a the property owner ar authorized agent to act zee the property aweer'sVbehalf I have read this application and the infmmatian I have provided is mImractj have read the Description of Work and verify it is acecrare. I agree to coutply with all applicable local ordinances and stare laws relating to buil�dingomy I antharize represeourtives of Cupertino to eater the above-id/Fn"properry for mspecoaa pnkposes. SignaturecfAppliandAgeae lf/e!i'r Dam: S` j� SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY m OYER-THFCOUNTER 6 ❑ EXPRESS Y • u ❑ sTAmARD u j ❑ LARGE ❑ MAJOR MEPdfaCApp_1011.daC revised 06121111