12050040 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20722 CARDEN PLACE CT CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 12050040
OWNER'SNAME: SHUHONG CHEN 1639 POMONA AVE DATE ISSUED:05/032012
OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)295-3911
El— LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL.
License Class C 3 joI.ic.p 6 1 REPLACE WATER SERVICE FROM METER TO HOUSE W/
{� 1 9 TYPE
Contractor p er ^� Date 'Z "L" COPPER PIPING
1 hereby affirm that 1 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 penally of perjury one of the following two declarations:
I have and will maintain a cenificate 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.Ft Fluor Area: Valuation:$200
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for Ore performance of the work for which this APN Number:36230063.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and stale that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.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 properly for inspection purposes. (We)agree to save 180 DAY F OM LAST CALLED INSP ION.
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 applicant understands and will comply Issued by: Date:
with all non-point source regulations Cupertino Municipal Code,Section
9.18.
�t RE-ROOFS:
Signature Date —� 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
1 hereby affirm that I em exempt from the Contractor's License Law for one of Signature ol'Applicant: Date:
the following two reasons: AL L ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the properly,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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE:
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safely Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth&Safely Cade,Section 25532(1)should I stare or handle hazardous
I have and will maintain a Cerlilicme of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emir hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District l
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino hluni ' .ode,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections
/25505, 5533 nal .34.
Section 3700 of the Labor Code,for the performance of the work for which this /./ � '/IxZ
permit is issued. Owner or authorized agent:llf///--- Dele.
I certify that in the performance of die work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
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,Cir C-)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that 1 have read this application and state that the above information is
cored.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 ,ARCHITECT'S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue 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: 20722 Garden Place DATE: 05103/2012 REVIEWED BY: Sean
APN; BP#: -VALUATION: $2,000
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Water Service
PRIMARY PENTAMATION 1CPWS
USE: Residential PERMIT TYPE:
WORK Re 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
Aleeh. flan Cherk Pharrb.Plon ChcrA Ete,7. Plan Check
birch. Amur Fee: Plumb.Permit Fee: 1PPERMIT G/ec. Renoir Fee:
Udno' 1/ern. Insp. Other Plumb lav,. $44.00 Orhto'Glc". /npj.
,I/e<h. bap. For: Plumb. hop. Fre. Elev. bop.Fee:
NOTE:This estimate does not includejees due to other Departments(Le.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prelimina information avaliable and are only an estimate. Contact lite Dept for addn'l info,
FEE ITEMS (Fee Resohaion /1-053 F17: 7/1/11) FEE QTY/FEE MISC ITEMS
Man Chcc-It 1''ee:
Sapp/. PC Fec
I'l t u n b.%,11e c h.%hl e c
Pennil Fee:
Srrppl. hrsp f2n: .
PME Unit Fee: $22.00
PME Permit Fee: $44.00
Consll'rlr'fion Kn.
A dmiurisuruive Fec.
Work Without Permit? O Yes No $0.00
Advanced Planning Fees:
Travel Docenterualiun Fees:
Srrnn4 dinlinn Fee Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $67.00 $0.00 TOTAL FEE: $67.00
Revised: 04/0112012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MIS C
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildine(ftuoertino.orD
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FIPLUMBING ❑NMCiAN-IICAz EjFr..ECTRICAL ❑MISCE rANIFOUS
FRogcrADDREss 2Q-7Z'Z rc).er, -`'\ace C—r AM* L(P2- d 0W
OWNER NAME -v U'� L /Y �01�f 1� oO 3 fit •
STREfTTADDRESS �� G. /G CIiS-TA y T FAX
CONTACT NAME 1 ( —(/G 7rA�;7
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COMPANY NAME' E-MAIL FAX
STREET ADORW • QTY,STATE ZIP FHONE
USE OFISM-Our= ❑ MULTFFAMRY FROIFITINWI DIAND ❑ YES PROJECTIN ❑YES ISTBIESLOGAN 11 YES
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BUOA'G: 13 GO11LyFArter URBAN INTERFACE AREA NO nDOD ZONE NO Ercmm HOME? 0
OFSC.7IP710N OP WORX po /
TOTAL VALUATION: ZooRECEIVED BY:
By Ory signature below,I certify to each of the follawiog. I am the property owna or anthmimd agent to act oa the property awner•s behalf I have read this
application and the ftnmmation I have provided is correct]have read the Description of Work and verify it is accurate. I agree to roomy with all applicable local
ordinances and state laws relating to building 'on. I mtbertze representatives of Coperdna to enter the above-identiflm property for inspecdon pu@oses.
Signature ofAppfi®NAgent _ Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
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❑ STANDARD
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❑ LARGE
❑ MAJOR
MEPMIrcApp_2011.dcc revised 06/21/11