12050037 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20719 GARDEN MANOR CT CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 12050037
OWNER'S NAME: Slit YU SUN&QING ZHU SONG 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 CONEN ERCI:tL
Llcensc Cl s C3,6 Lic.q �r.50� REPLACE WATER SERVICE FROM METER TO HOUSE W/
L TYPE
Commdo f`P� P1, 6" Date C_/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.
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 Labra Code,for the
perfommnce of the work for whichthis permit is issued. Sq.FI Floor Area: Valuation:$200
I have and will maintain Workers Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for whigh t APN Number:3623007400 Occupancy Type:
permit is issued.
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.I agree to complywith 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 ROM LAST CALLED INSP ON.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Z
granting of this permit. Addition the�plicam understands and will comply Issued by: L Date:
with all non-point source reg atims p the Cupertino Municipal Code.Section
9.18. J
/ (Z RE-ROOFS:
Signmurc f�r� 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that 1 am exemptfrom the Contractor's License Law for one of
the following Iwo reasons: ALL ROOF COVERINGSTo BE CLASS"A"OR BETTER
1,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(See.7044,
Business& Professions Code)
I,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. I 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: Health&Safety 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 Quality Management District
performance of the work for which this permit is issued. will maintain compliance with the Cupertino 111 al Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the llealth&Safety Code,Sections 25505.25 ,a 25534. /
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agen( � Date:
permit is issued
I certify that in the performance of the 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 Cali forma. 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,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
coffee[.I agree to comply with all city and county ordinances and state laws relating
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes-(We)agree to save ARCIIITECT'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: 20719 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 PENTAMATION 1CPWS
USE: Residential PERMITTVPE:
WORK Re lace the water service from the meter to the house with type "L" copperpiping.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID BP FEES
Water Service Unit Fee: 1BPWSVCS $22
1•lav C'hLt'
k /'boob. Plan C11crd Flee. Phu?Chcck
. Pm'mit Fcu: Plumb.Permit Fee: IPPERMIT /:7er. 1'drmil I.c:
oibcr 1im h. Odrer Plumb Insp, $44.00 (ldrer/ilrr. bap.
Hoch, /nsp. l"'rr. Plumb. hr.sp. hap. 1'.rr:
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitaq•Sewer District,School
District,etc). These fees are based on the preliminarY information available and are only an estimate. Contact the Dept for adtln 7 info.
FEE ITEMS (Fee Resolution 11-053 Ell: 7/1/1 U FEE QTY/FEE MISC ITEMS
Plum Check Felt:
Supp/. PC liar
Plrnnh_!rhlech.E lec
Pe nnil /•i:c:
S'nppl. h 'p Fee
PME Unit Fee: Z$22.00PME Permit Fee: 4.00
Conclrurtion 7"n:
;Ir/mimstrurive Fre:
Work Without Permit? O Yes Q No $0.00
I :Idrmcerd l'huvniryt; Fees:
Travel Documentation FLICS: A
Slran,q d/u/irnr Fc•c: Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $67.00 $0.00 TOTAL FEE: $67.00
Revised: 0 4101/201 2
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DNISION
10300 TORRE AVENUE•CUPERTINO,CA 950143255 M I A
CUPERTINO (408)777-3228•FAX(408)777-3333•buildino(5cuoertino.org (v'
PLUMINGp❑MCHANICAL ❑ELECTRICAL ❑MISr�-Til 205'
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PROcrADDRESS ZcU�7 (� 4rD•etr. (/t/IQY+Or^ C_r� APNa 36a 3v G 7
OWNER NAME ✓/� PHONE��G JOU E-MAIL
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CONTACTNAME +; l\` SL —Y4 FECN%�o S'7/I� / E Co..Te17 �� /r..t�i .Cs,*�
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CONTRACTOR NAME �`t(lll p �1 L� r3@1SE NUABE7lCsVITOG / LICENSE r--3 ) BUS.FICA
COMPANY NAME �Utl,..!'Yll VVLNrJb I n 1 E.v.rt�1S, b t`C'�//G� LKs Cr_ FAX q,9,9 Z 23'3 4/!
STREETADDRESS/6.3"1
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ARCH=/ENGINEER NAME LICENSE N NMER. SOS.LIC N
COMPANY NAME E-MAIL FAX
snuMM ADORF_cs CITY.STATE,ZIP PHONE
USE OF .DUPLEX ❑ muLnFAKiLY FROIFITIN WItDfAND ❑ YES PRO=W ❑YES ETRE 31 DG AN ❑YES
3UIDINQ ❑rpNL.4Rrt.r URBAN INTERFACE AREA NO FLOOD ZONE NO pCID1:.5 HOM£l �NO
ot-s e e w XCoe
TOTAL VALUATION: �QO Wil" RECEIVED BY:
By my signature below,I certify to each of the f3llawing I am the property owacr or aaththorimd agent to am on the property owner's behalf I have read this
application and the irdbrmatioo I have provided is correct have read the Descriptio¢of Work Rad verify it is accurate. I agree to comply with all applicable local
ardmmrces and stare laws relarog�to 6m/�dmg I aothoria representatives of Cupertino to cuter the dynefic�propcM for inspccoon pul-ases.
SigaaDaeof AppE®t/Agene 2! Date: /3 lez
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
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MEPMUCApp_2011.dac revised 06/21/11