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09070074 CITY OF CUPERTINO �7 BUILDING DIV' 1014 PERMIT � Z� TT�11 BUILDING ADDRESS: PERMIT NO. 22090 HIBISCUS DR MASTERI;ERV IN VNER'S NAME: PERMIT ISSUE DATE PHO -960 T=1_BFVPRy SIP SA Y CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO REPIPE HOME REPLACE MAINLINE BLDG ELECT PLUMB MECH D D O O u O p LICENSED CONTRACTOR'S DECLARATION IN COPPER PIPE U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is y in full force and effect. License asa Lic.ff n t- Date Contrac CHITECTS DEC A a< understand my plans shall be used as public records DyU LC y Licensed Professional 0.1 OWNER-BUILDER DECLARATION jt m I hereby affirm that 1 am exempt from the Contractors License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county <� which requires a permit to construct,alter,improve,demolish,or repair any structure n Z prior to its issuance,also requires the applicant for such permit to rile a signed statement _C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation y F (commencing with Section 7(X10)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars(5500). ❑I,as owner of the property,or my employers with wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for We.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sec. B&P C for this reason 'nerDate WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Workers compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker Com nsa'on In ace carrier and Policy her am- Carrie Policy No.+ 1(��►L r� ChKIINUArg OF EXEMPTION FROM WORKERS'?c�,� � COMPENSATION INSURANCE CT (This section need not be completed if the permit is for one hundred dollars($100 or less.) I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z" CONSTRUCTION LENDING AGENCY [~a 4 I hereby affirm that there is a construction lending agency for the performance of Q!> the work for which this permit is issued(Sec.3097,Civ.C.) a Q Lender's Name Lenders Address U 0 1 certify that I have read this application and state that the above information is L%L`' correct.I agree to comply with all city and county ordinances and state laws relating to (0V building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against c4,j liabilities,judgments,costs and expenses which may in anyway accrue against said City U Z in consequence of the granting of this permit. Date �+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: so REGULATIONS r 9 Re-roofs Ztk&ire ofd HAZARDOUS MATERIALS DISCLOSURE Data Type of R sof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -le,Section 25532(a)? All roofs:ihall be inspected prior to any roofing material being installed. ❑Yu ❑No Will the applicant or future building occupant use equipment or devices which If a roof i:;installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new in iterials for inspection. District? ❑Yes ❑No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant that it is my responsibility to notify the occupant of the mqu' a which must met prior issu a Certificate or cu cy. Signature 3f Applicant Date o err antboriD All roof coverings to be Class's/ `'or better CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot : APN . . . . . . . . : 32602030. 00 DATE ISSUED. . . . . . . : 07/07/2009 RECEIPT #. . . . . . . . . : BS000008150 REFERENCE ID # . • • 09C70074 SITE ADDRESS . . . . . : 22C90 HIBISCUS DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : COLSON KENNETH E AND JUDITH A ADDRESS . . . . . . . . . . : 22C90 HIBISCUS DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0109 RECEIVED FROM . . . . : MASTERSERV CONTRACTOR . . . . . . . : GECRGE ANDERSON LIC # 30854 COMPANY . . . . . . . . . . : MAETERSERV INC ADDRESS . . . . . . . . . . : 56C LIBRARY ST CITY/STATE/ZIP . . . : SAIS FERNANDO, CA 91340 TELEPHONE (8C0) 806-7674 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 950 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 4, 950 . 00 0 .50 0 . 00 0 .50 0 .00 1PPERMITFE FLAT RATE 1. 00 42 .00 0 . 00 42 . 00 0 .00 1PRREPIPE NO OF FIXTURE 6 . 00 66 .00 0 . 00 66 . 00 0 .00 1TRAVDOC FLAT RATE 1. 00 42 .00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 151 .50 0 . 00 151.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 151 . 50 visa --------------- TOTAL RECEIPT 151 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING r. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 cir 0V Fax(408)777-3333 CUPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: / PHONE # LrrOfp GENERAL CONTRACTOR: .412, .( FAX # I am not using any subcontractors:A 0` fl Si!;nature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile n Ver/Contractor Signature Date Jul. b. 2009 12: 07PM MasterServ, Inc. No. 8842 P. 4 CITY OF C'UPERTINO REPIPE/SEWEIVMIN SER'V'ICE CUPERTINO PERMIT APPLICATION FORM 0 led 7Z --- APN# oa� O✓v •� Date: Building Address: ."9,0 0 14191 9j S c`)-S L) Owner's Name: Ke—n t-,70 01 T H � � Phone �?—0 3 6[�l Contractor: �A NS•.c a C,.+ ,?—Q `,,��r Phone#: . lT, Fax#: Q,1 - 14100 Contact: Phone#: •--906 7 Fax#: Contractor License#: 0017 Cupertino Business License#: Job Description: V f-10,.Q Residential Commercial Valuation: qc� r5 Project Size: Express Standard Large[) Major Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable,include in plan set&ibe sheet index. Green Building Points: Quantity Fee YD Fee Description Fee .hermit Type Group 1PCSEWER Commercial building P ICPSS sewer/sanitary s,,wer 1BPREPIPE Commercial re-l;ipe per fixture P 1CP" 1POASCOM Commercial Cra:c Piping System P 14 Outlets 1BCBSC Cal Bldg Standards Commission B .ALL PEI ' Pee TYPES 113SEISWCOM Seismic Commercial P Revised 01/07/09 Jul. 6. 2009 12: 07PM MasterServ, Inc. No, $$42 P. 5 ac,10 CITY O \SIJ-PERTINO REPIPE/SEWEIGMAIN SERVICECU 'iING FEE SC HEDUEE Quantity Fee XD Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standar3s Commission B ALL PERMIT Fee TYPES IBSEISMICR Seismic Residential P IPR.SI;WER Residential build ng P IRPSS sewer/sanitary sever 1PRREPIPE Residential re-pile per fixture P IRPRP IBPWSVCS Service P ICPWS or IRPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P IBPWATER Install/alter Water Pipe P 113PPIXTURE Plumbing Fixture P IPGASR.ES Residential Gas Piping System P 1-4 Outlets 113POAS Gas Piping System S+Outlets P p IPPEIZMITFEE Plumbing Permit Fee Issuance P 1 1PL1YML'NCK Plumbing Plan Clieck P IPUDINSP Other Plumbing/j;as Insp. P ITRAVDOC Travel&nocurntmtation Fee B i IBUSLIC Business License B