12050042 CITY OF CUPERTINO BUILDING PERMIT
BUILDING.ADDRESS: 20725 GARDEN MANOR CT CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 12050042
OWNER'S NAME: ALBERT&ALICE FONG 1639 POMONA AVE DATE ISSUED:05103/2012
OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)295-3911
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERQ,U.11
License Class C— Lic.q � 9 REPLACE WATER SERVICE FROM METER TO HOUSE W/
TYPE
Commctor "�ry3�e� " ' Date 3 Z "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 which this permit is issued. Sq.FI 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 for whjch this
(^ /, / Y yr^ APN Number:36230073.00 Occupancy Type:
permit is issued �`..`J
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
cored.1 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 DA F OM LAST CALLED IN7a;
TN.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the licam understands and will comply Issued by: Date:
with all noo-point source regulatiah a penin Municipal Code,Section
9.18.
RF.-ROOFS:
Signature Dale `�/`3//Z— All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date
I hereby alTirm that t am exempt from the Contractor's License Lew for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my caployces 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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE;
construct the project(Sce.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 penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(1)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 Airu lily Management District 1
performance of the work for whichthis pernit is issued. will maintain compliance with the Cup rlino nicipa Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5, an 55
Section 3700 of the Labor Code,for die performance of die work for which this Owner or authorized agent Dale:'-" J
permit is issued.
I certify that in the performance of die work for which this permit is issued.I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of Cal ifamm. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NCV
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm 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
1 certify that I have read this application and state that the above information is
correct.I agree to comply with ail 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 ARCHITECT'S DECLARATION
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs.and expenses which may aceme against said City in consequence of the I 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 Date
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 20725 Garden Manor Ct DATE: 05/03/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $2,000
"PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Water Service
PRIMARY Residential PENTAMATION 1CPWS
USE: I I PERMIT TV PE:
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
dlveh. Plan Chrck Plumb. Plmi ChceS F.lec. Plmr L%as:k
.1 t,,J, /'rr,,0 Fee: Plumb. Permit Fee: IPPERMIT tiler.-. 1'armil Fee:
Ocher;iferh. Insp. 0rher Plumh In.sp, Li $44.00 Ocher Elec.lar,.
,lirrh. h"p. Fre: Plumb. htrp. Fee: rhx.ln.¢. Fire:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,eta). Thesefees are based on the prelimina information available and are only an estimate. Contact the Det or addn7 info.
FEE ITEMS (Fee Resolution 11-053 E(1: 7/1/I1) FEE QTY/FEE MISC ITEMS
Ph in Check !cc,.
.Supp!. NC Fier
PlmnhAlli-ch./Elec
fermi! Fart.
Sup/)/. lusp l e e
PME Unit Fee: $22.00
PME Permit Fee: $44.00
(W IS0 11(7id11 KIN.
Aorninisiregive Pee:
Work Without Permit? O Yes 0 No $0.00
Advanced plunning Feer:
•Tnivcl Uocrrrnenlulinn Feee': A
Srr„nq ,blonrru Fee: Select an Administrative Item
Bide Stds Commission Fee: IBCBSC 1 $1.001 1
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 MIS C
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildingecuoertinc.ora
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CONTRAROR NAME �I`t(l�f(( R �11 .C4 I3�dSENUMBERgIVI n,( //��t,[�•ISE /�� 7 BUS.Lica
COMPANYNAME �� �Cra,J'VtII VVLNnIY)r n ' E.MAR./'2.1C1KL a be ,RXw3,,- FAx el_,S) Z2�34i!
sTREETAnaRFss�CaS' Tvmoc.ict A- arY,srCAP�-+n �oSt �c1 PE°NE�8- -7 -�-2
ARC IU=/ENGINE E&NAME LICENSE NUMBER HUS.LIC A
COMPANY NAME' E-MAI. FAX
STRh2T ADDRESS CTIY,STATE,ZIP PHONE
USE OF .13UPIFS ❑ MULTI-FAMILY PROTFCTINWIIDEAND ❑ YES PROJECT N [IYES IS THE BLDG AN 13 YES
etrHDNG: ❑CUMMERCL r URBAN OYTFRFACEAREA No FLOOD ZONE NO ER7TIER RDS41 �NO
DFSCR1PfION Of WORK RI '� T -
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I C � UYG� T'VbM 1 •�s..tt_�c WteACl'
r/ r/
o�S e r n e-
TOTAL VALUATION: �QO e��' RECEIVED BY:
By Dry signature below,I testify to each of the IbIIDWIDg'. I am the property owner or authorized agent to act ou the property owner's bchal£ I have read this
application and the ioformatioa I have provided is correct the Description of Work and verify it is accursm. I agree m couspiv with all applicable local
ordinances and stare laws relating to buil ' coason d Ian ' e representatives of Cupertino to cater the above-idSn Ipropnry far iospecdea pu@oses.
Signature of Appli®VAgcae 1 Date: 3 !L
SUPPLEMENTAL INFORMATION REQUIRED oma USE ONLY
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MB1`MLrcApp_2011.doc revised 0621/11