12050204 CITY'.OF'CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7555 HOLLANDERRY PL CONTRACTOR:TRIPLE A PLUMBING PERMIT NO: 12050204
SERVICES
OWNER'S NAME: LIU KEN H AND TRACY E PO BOX 5144 DATE ISSUED:05/29/2012.
OWNER'S PHONE: 6509480805 SANTA CLARA,CA 95056 PHONE NO:(408)2454940
❑ LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class_ Lic.q i''"/ b- 1 r r r
- MECH RESIDENTIAL COMMERCIAL
Conlractor Iip hf _. Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-ROUTE 1 INCH WATER MAIN FROM CITY MAIN TO
(commencing with Section 7000)of Division 3 of The Business&Professions HOUSE,INSTALL A PRESSURE REGULATOR
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 9700 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 pedorni mcc o the work for which this Sq.FI Floor Area: Valuation:$3000
permit is issued.
APPLICANT CERTIFICATION APN Number:36226059.00 Occupancy Type:
I certify that I have read this application and state that the above information is
correct.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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. / / �"N/-
Issued by: /^ k /7/G� Date:
Signature
❑
OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offeredfor sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business&Professions Code), ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which[his permit is issued. California Health&Safely Code,Sections 25505,25.533,and 25534. I 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 the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should 1 store or handle hazardous material,
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which 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 become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I �7 Q
become subject to the Worker's Compensation provisions of theLabor Code,I must OyverizeJent: a`—/ �Z
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and stale that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state 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 liabilities;judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36226059. 00
DATE ISSUED.. . . . . . : 05/29/2012
RECEIPT 4. . . . . . . . . : BS000016928
REFERENCE ID # . . . : 12050204
SITE ADDRESS . . . . . : 7555 HOLLANDERRY PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . .
OWNER . . . . . . . . . . . . : LIU KEN H AND TRACY E
ADDRESS . . . . . . . . . . : 26751 ALMADEN CT
CITY/STATE/ZIP . . . : LOS ALTOS HILLS, CA 94022-4316
RECEIVED FROM . . . . : KENNETH L DENSON
CONTRACTOR . . . . . . . : MARCO. A REGALADO LIC # 29716
COMPANY . . . . . . . . . . TRIPLE A PLUMBING SERVICES
ADDRESS . . . . . . . . . . : PO BOX 5144
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95056
TELEPHONE . . . . . . . . : (408) 245-4940
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 3, 000 .00 1 . 00 0 .00 1 .00 0. 00
1BPWSVCS WATER SERVICE 1. 00 22. 00 0 . 00 22 . 00 0. 00
1BSEISMICR VALUATION 3, 000 .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 152 . 50 0. 00 152.50 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- --------------------------- -------- ----------------------------
106
------ -------------
106 SEWER & WATER 301 ROUGH PLUMBING
507 FINAL PLUMBING
l
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 7555 HOLLANBERRY DATE: 05/29/2012 REVIEWED BY: SEAN
APN: BP#: VALUATION: $3,000
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPWS
USE: PERMIT TYPE:
WORK REROUTE 1 INCH WATER MAIN FROM CITY MAIN TO HOUSE INSTALL A PRESSURE
SCOPE REGULATOR.
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BPFEES
Water Service iBPWSVCS 1 # $22
TOTALS: $22.00
d-L ch. l7un Ch,:ck Plumb.Plan Check 0.0 hrs $0.00 Ele,- Plow Cherk
dh•cb. P,•rma Fee: Plumb.Permit Fee: IPPERMIT Flec.Permir Fre:
orhr, Me,h. Insp. Other Plumb Insp. 0.0 hrs $44.00 Order rle-c_Imp.
dh(It. ba,p. Fre: Phoub. bsp. Fre: Elev. In¢. Fee
NOTE: This estimate does not includejees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Re.sohnion 11-053 E/L 7/1/1 U FEE QTY/FEE MISC ITEMS
PLun Cln:rh Fuc::
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fix:
Suppl. lnsp Fee
PME Unit Fee: $22.00
PME Permit Fee: $44.00
Cunsrruction Tax.
Administrative Fee: (ADMIN $41.00
Work Without Permit? O Yes 0 No $0.00
Arlranced Plurruin,>; Fees:
Travel Documentation Fee: ITRAVDOC $44.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $152.50 $0.00 TOTAL FEE: $152.50
Revised: 05/01/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITYDEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO. CA 950143255 M I
sc
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinG cDcupertino.oro
PLUMBING MECHAMCAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECTADDRES 5lfi
11^ APNI
OWNER NAME \ l PHO'J�SjE-MAIL \(l l
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STREETADDRESS� J O ^ CITY. STATZIP FAX
CONTACT NAME V' PH NE // E-MAIL
STREET ADDRESS /I A FAX
13 OWNER 13OWNER-B")t/DDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENOWEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME O LICEN
LICENSE TYPE/ BUS.LIC p
COM .ME
PANYNA — E-MAIL C/ FAX
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STREET ADDRESS, , TATE,IIP PHONE
0 721
ARCHiTECTIENGINEER NAME _ LICENSE NUMBER BUS.LIC p
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE
USE OF LM.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WI DLAND ❑ YES
PROTECT W ❑YES IS THE BLDG AN VimBI/IIDP'O: COMMERCLLL URBAN INTERFACE AREA NO FLOOD ZONE NO ECHIFR HOME± O
DES ON OF WOR% Ir I
rnS-(rA-1 in a-r;n,r
TOTAL VALUATION: D RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf 1 have read this
application and the information 1 have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building striction. I authorize representatives of Cupertino to enter the above-identified proper-,y for inspection ptiposes.
Signature of Applicant/Agent:. Daze:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
W OVER-THELOUNTER
❑ EXPRESS
Y
U
W ❑ STANDARD
U
Z ❑ LARGE
❑ MAJOR
Ag)PMa'cApp_2011.doc revised 06121/11