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12060082CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22105 LINDA VISTA PL CONTRACTOR: 13AYSI ]ORF PLUMBERS PFRMI'I NO: 13060082 OWNER'SNAME: NGUYEN KI IANI I BAND DAO'I'I IANI1 T PO BOX 2579 DA I L' ISSUED: 06/14/2012 OWN ER'S PI PONE: 4088879586 MENLO PARK. CA 94025 P110Ne SD:(650)323.6464 ❑ LICENSED CON'TRACTOR'S DECLARATION r r r fes( ^O�,^r_ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic•.N DCIV I I— r— r Glllmclnf j^y;hprQ puPp Ic NIECII RESIDENTIAL COMMERCIAL I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RFPLACE I I I E WA'I'I:R MAIN FROM Sllal!R TO I I(lM li (commencing with Section 7000) of Division 3 of the Business & Professions 73171 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 hake and will maintain a certificate of consent to self -insure for W'orker's Compensation, as provided Iia by Section 3700 of the Labor Code, for the performance of the work fur which this permh is issued. Sy. Ft Floor Arco: Valuation: S2700Section I have and will maintain Worker s Compensation Insurance, as provided for by 3700 ofthe Labor Code, lir the performance of the work 1'or which this permit is issued. APN Number: 35608013.00 Occupancy'Iype: APPLIC:ANI CERTIFICATION I certiJN than I have read this application and state dial the above information is correct. I agree to comply with all city and county ordinances and slate laws relating m, building construction, and hereby authorize representatives ofthis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon tine above mentioned property for inspection purposes. (We) agree to save ndcmnil'yandkeepharmlesstheCityofCupertinoagainstliabilities,judgments, WITHIN Igo DAYS OF PERMIT ISSUANCE Oil costs, ;aid e%pcnscs which may accrue against said City in consequence ofthc Igo DAYS FROM LAST CALLED INSPECTION. griming ol'this pennon. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Issued by: J�> /V Dale: (r�'i`�•('� Signature Date IO/ ( 4/ /z- �i i` ❑ OW'NP:It-BUILDER DF,CLARAI'ION Rt: ROOFS: All moll shall be inspected prior w any roofing material Icing installed. 11 it root' is hereby affirm that I ctrl exempt from the Contractor's License Law for one of installed without first obtaining an inspection. I agree to remove alt new materials lir the following Iwo reasons: inspection. 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 ollered for sale (Sec.7044. Signature of Applicant: Date: Business & Professions Code) I, its owner (it the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044. Business & Professions Code). ALL ROOF COVERINGS 10 IIF. CLASS "A" Olt BE 1-1 Lit I hereby affirm under penally of perjury one of the following three decl: to lions: IIA%ARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self -insure for Worker's I have read the hazardous materials requirements under Chapter 695 of the Compensation, as provided for h)' Section 3700 of the Labor Code, for the California Ilealth & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain performance of the work for which this permit is issued, compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth & I InDe and will maintain Worker's Compensation Insurance, as provided for by Safety' Code, Section 25532(x) should I store or handle hazardous material. Section 3700 of the labor Code, for the performance of the work for which this Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will I lernin is issued. maintain compliance with the Cupertino Municipal Cole, Chapter 9.12 aril the I certify that in the performance of the work for which this permit is issued, I shall Ilealth & Safely Code, Sections 25505, 25533, and 25534. still employ anyperson in any manner so as to become subject to the Worker's Compensation laws of -California. If after making this certificate of exemption, I Own • n IN•d agent: hcunne subject to the Worker's Compensation provisions nl'Ihe Labor Code, I must -- Date: 6 ( L forthwith comply with such provisions or this permit shall be deemed revoked. CONS 'Ilit CION LF:N'DINC. :\GF:NC\' APDL ICA.N'T CERT IFICATION I hereby affirm that there is it construction lending agency lir the performance of work's I certil'y' than I have read this application and state that the above information is lox which this permit is issued (Sec 3097, Civ C) correct. I agree to comply with all city and county ordinances told state laws relating Lender's Name to building construction. and here6) authorize representatives of this city to enter upon the ahuve mentioned property ['or inspection purposes. (We) agree to save Lender's Address indenmiR and keep harmless the City of Cupertino against liabilities, judgments. costs, told expenses which may accrue against said City in consequence of the granting of this permit. Additionally'. the applicant understands and will comply _ ARCM"I_ EC I"S DF,CLARA'I'ION with all non -point source regulations per the Cupertino Municipal Code, Section I understand my plans shall he used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO ISI FEE ESTIMATOR - BUILDING DIVISION LM-FADDRESS: 22105 Linda Viita,Jj#-p[ DATE: 061 1 412 01 2 REVIEWED BY: Sean UNITS APN: BP#: aQ U 'VALUATION: $2,700 yPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $22 PENTAMATION 1RPWS PERMIT TYPE: WORK Re lace the water main from meter to home 73 ft). SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES .-I"e. Puvnif Fero: Water Service IBPWSVCS Other 1 -.lc(. lay. Ej 1 # $22 Pennif For.: Suppl. hup Fee PME Unit Fee: $22.00 PME Permit Fee: $44.00 C'unsfruction Ta.r: Administrative Fee: 1ADMIN $41.00 Work Without Permit? O Yes Q No $0.00 TOTALS: i Travel Documentation Fee: ITRAVDOC $22.00 Shone Motion Fce: IBSEISMICR NOTE: This estimate does not mcludejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. Thesefees are based on the prelimina information available and are only an estimate Contact die Dept for addn7 info. FEE ITEMS (Fee Rc,snlurinn 11-053 Eff 7/11111 A lvch. Wan ('hack Plumb. Plan Check 0.0 1 hrs $0.00 /:7e.:. Plan Check ditch. Permit Fee: Plumb. Permit Fee: 1PPERM/T .-I"e. Puvnif Fero: Olhe, Afrrh. Imp, Other Plumb Insp. 0.0 hrs$44.00 Other 1 -.lc(. lay. Ej ,I A%h. imp. Fw: Phanb. N.y. Fee: fifer. Lisp. FCC. NOTE: This estimate does not mcludejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. Thesefees are based on the prelimina information available and are only an estimate Contact die Dept for addn7 info. FEE ITEMS (Fee Rc,snlurinn 11-053 Eff 7/11111 FEE QTY/FEE MISC ITEMS Plan Chuck Feer Suppl. PC[.-(,(.' PME Plan Check: $0.00 Pennif For.: Suppl. hup Fee PME Unit Fee: $22.00 PME Permit Fee: $44.00 C'unsfruction Ta.r: Administrative Fee: 1ADMIN $41.00 Work Without Permit? O Yes Q No $0.00 ;I rAYMCed Planning Fecv: i Travel Documentation Fee: ITRAVDOC $44.00 Shone Motion Fce: IBSEISMICR $0.50 Select an Administrative Item 131de Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $152.50 1 $0.001 TOTAL FEE: 1 $152.50 Revised: 06/05/2012 7 ITEMS OF 7 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35608013.00 DATE ISSUED.......: 06/14/2012 RECEIPT 4.........: BS000017068 REFERENCE ID # ...: 12060082 SITE ADDRESS .....: 22105 LINDA VISTA PL SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OPERATOR: suew COPY # : 1 METHOD OF PAYMENT -------- CHECK TOTAL RECEIPT : AMOUNT --------------- 271.50 --------------- 271.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 507 FINAL PLUMBING REFERENCE NUMBER ------------ 2593 VOICE ID DESCRIPTION ---- - ------------------ 301 ROUGH PLUMBING OWNER ............: NGUYEN KHANH B AND DAO THANH T ADDRESS ..........: 22105 LINDA VISTA PL CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: BAYSHORE PLUMBERS CONTRACTOR ... :... : SAMUEL JIMENEZ LIC # 32512 COMPANY ..........: BAYSHORE PLUMBERS ADDRESS ............: PO BOX 2579 CITY/STATE/ZIP ...: MENLO PARK, CA 94025 TELEPHONE ........: (650) 323-6464 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 2,700.00 1.00 0.00 1.00 0.00 1BPWSVCS WATER SERVICE 1.00 22.00 0.00 22.00 0.00 1BSEISMICR VALUATION 2,700.00 0.50 0.00 0.50 0.00 1BUSLIC FLAT RATE 1.00 119.00 0.00 119.00 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 ---------- ---------- 271.50 0.00 ---------- 271.50 ---------- 0.00 METHOD OF PAYMENT -------- CHECK TOTAL RECEIPT : AMOUNT --------------- 271.50 --------------- 271.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 507 FINAL PLUMBING REFERENCE NUMBER ------------ 2593 VOICE ID DESCRIPTION ---- - ------------------ 301 ROUGH PLUMBING Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: Qq A ' `hist PC, PERMIT # !Z 2 OWNER'S NAME: Kharh, (v t4VI PHONE # 5S (p GENERAL CONTRACTOR jFAX # I am not using any subcontractors: VZ gnature Date Please check applicable subcontractors,and co vlete the following information: Owner/ Contractor. Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing,_ Electrical Excavation Fencing Flooring. Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Omamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor. Signature Date a6, GENERAL.PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION (408) TORRE'AVE FAX (4 • CUPERTINO, CA 950143255Id �� I CUPERTINO (408)'777-3228 •FAX (408)777-3333 • buildinatD'�cuoertino.DrD SC / ..O^ /�� ZPLUM13ING •- 0Iv1ECHAMCAL ❑ELECTRICAL ❑MISCELLANEOUS PRDIECI' ADDRE55 .2 2J -109 u i1� V I s � � & APN q 3,5&—o,5- 5&—v,OWNER OWNERNAME 1'--kAv-h N ti,,1 e h`' "°o STREET ADDRESS 22195 LI vi [/LGL 'V 15 � �p�QNA1�FKKO r'* FAX CONTACT NAME per (c.,, rQS l0 `JV f% IOT MAB. STREET ADDRE S�, ` �D( (S�� ,SATE, Z' ^ Q t aCONTRAC FAX ❑ OWNER ❑/�J.OE�rW�NIERZBBUUIILDM OWNERf AAG_FNT ❑,CONTRACTOR OR AGENT ❑l M(]DTE T ❑ ENGM ER ❑ DEVELOPER ❑3 TaW4T q�❑ Q NS, IO' C LI 5 ER LiCEN`%E G (� BUS. LTCq •�^✓! COMP NAME SYtoJ� r�Iu� E -MAR F ��(✓! �D STREET ADD SS t�lLsovl cv-I e �Yo� 632 65^� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC q COMPANY NAME - E-MAIL l FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF sm a OUPLEX ❑ MIRTI-FAMILY. BUILDING: COMMERCI . : PROTECT IN WILDLAND ❑ YES URBAN INTERFACE AREA NO PROJECT IN ❑ YES FLOOD ZONE PLNO IS THE BLDG AN ❑ YTS EICHLER HOME JR NO DESCRIPTION OF WORK waf _-fri�wL rr� �3 F`I TOTAL VALUATION: 21�DQ� RECEIVED BY: By my signature below, I certify to each of the following: .I nm the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is w=L 1 have read the Description of Work and verify it is accurate. I agree m comply with all applicable local ordinances and state Taws relating to building co tru tion_. 1 aurhon= mpresentadves of Cuperono to enter the above-iydd� Bed propery Cor inspection pui oses. Sigatau a of Applicant/Agene Dare: "J � ( 2 LEMENT INFORMATION REQUIRED OFFICE USE ONLY y OVER-THE-COUNTER E Y ❑ EXPRESS V m U ❑ STANDARD ❑ LARCE c ❑ MAJOR MEPMu'cApp-1011.doc revised 06/21/11