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12080200CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 10386 PLUM'1'REELN CONTRACTOR: MASTERSERV INC PERMITNO: 12080200 OWNER'S NAM E: RUDSTROM-VACI]ON LINDA 560 IJBRARVST DA'Z'E ISSUED: 08202012 OWNER'S PHONE: 4083966180 SAN FERNANDO. CA 91340 PHONE NO: (800) 8116-7674 LICENSED C0NI'BACI'0R'S DECLARATION BLDG PLUMB - License Classes Lie. « L7 �-bQO BUILDING PERMIT INFO: ELECT. r r r. MEcn RESIDENTIAL coA1n1ERc1AL �11 \ n^�^ Contractor VYI6rlef7♦ Olx✓ Date t—l0-111 hereby alTnn that l am licensed under fire provisions of Chaluer9 JOB DESCRI P'r1ON: COPPER REPIPE AND REPLACE MAIN SERVICE LINE (commencing wish of Ilar Iinsinrss S Professions and 3 isSectionsi in fu e Code and that my license is in full force and eHcrf. roe I hereby affirm under penally of perjuryone the following wax ra li0m: Lk ker's I have and w'111 maintain aalCCcertificateof COOSI'11110 10 sell -111511f1' for WOfkc't 5 Compensation, as provided I'or by Section 3700 of the Labor Code, for the perfommnce of the work for which this pemmil is issued. a� p1. n Sq. Ft Floor Arae }A Valuation: $5800 I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of die work for which this V s permit is issued. ,\I'N Number: 31633Q20.00 Occupancy'Iypa .\I'1'LIGN\ 1' fli lt'I'IPIG\'PION FF�`99 I certify that I have read this application and state that doe above inf nniation is / correct. I agree to comply With all city and County ordinances and state laws relating to building Wllslr11C1100, and hereby and10r1%a reprl'sl'an111Y1'S OI 4115 C1t'fO enter PERMIT MOIRES IF WORK IS NOT STARTED upon Ilse above mentioned properly for inspection purposes. (We) agree f0 save oq indemnify and keep harmless the City of Cupertino against liabilities, judgments. WITHIN480 DAYS OF PERMIT ISSUANCE OR costs, and expenses which may acerae against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Addi (tally, the applicant understands mid will comply with all non -point source re lions per Lite Cupertino Municipal Code, Section ( r 9.18. Issued by: \J �� Date: Signaum Date r� - ✓ �� ❑ OWNER -Ii III LDE11 DECLARATION RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is hereby aff irm Ihm I am exempt from the Cunlracfur's License Law for (tire of installed without first obtaining an inspection, 1 agree to remove all nein materials for the following two reasons: inspection. 1, as owner of the property, or my employees With wages as their sale conmpcusali0n, will do the work, mid the structure is not intended or offered for sale (Sec.7044, Signature of Appliane Date Business R Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business C Professions Code). ALL ROOF COVERINGS TO BEI CI„\SS "A" OR ISIS ITEM 1 hereby affirm under penalty of perjury une of Ihr following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate ofConsenno self4tisure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the COmnpensation, as provided for by Section 3700 or tire Labor Code, for the California Ilaalth & Sa rely Code, Sections 25505, 25533, and 25534. I will maintain performance of the work for which this permit is issued. compliance with Ihr Cuperlino Municipal Colo Chapter 9.12 and the Ilcalth S I have and will maintain Worker's Compensation Insurance, as provided for by Safely Code, Section 2.5532(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 I use equipment or devices which emit hn¢urdous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code. Chapter) 1_ and the I certify that in the performance of die work for Which this pemnil is issued, I shall Health S Safely Code, Sections 25505. 25533, and 25534. not employ :my person in my manner so as to become subject 10 (lie Worker's Compensation laws of California. If, after making this certificate ofexemption,l Ow ner ur--outhori% agent.. ��%-� 'Blue: — become subject to the Worker's Congmensmion provisions of the Labor Code I musti� tea"��/r� Im-t wwith comply with such provisions or this permit shall be deemed revoked. CONSTRl1C110N LI?NDING AGENCY APPLICAN f CP:RTIFICATION I hereby affirm that there i5 a construction lending agency for the performance of work's I certify that I have read this application and state Thal the above infomnation is for Which this permit is issued (Sec. 3097, Cir Q correct. I agree to conmplyw•inh all city and county ordinances mid state laws relining Leader's Name to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Lender's Address indemniN and keep harmless tire City of Cupertino against liabilities, judgments, costs, and expenses which may accmc against said City in consequence of the granting of this permit Additionally, the applicant understands and will comply ARCI IITEX-I"S DECLARATION with all non -point source regulations per the Cupertino Municipal Code, Section 1 understand my plans shall be used as public records. 9.18. Licensed Professional Sigmiature Date CITY OF CUPERTINO FEE ESTIMATOR -BUILDING DIVISION APPLIANCE/ EQUIP TYPE ADDRESS: 10386 Plum Tree Ln DATE: 08/20/2012 REVIEWED BY: jsg UNITS APN: BP#: 'VALUATION: 1$5,800 *PERMITTYPE: Plumbing Permit PLAN CIIECK Tl'PE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex $13 I PENTAIIIATION PERMIT TYPE: 1RPR WORK Copper re i e and replace main service line SCOPE 1 APPLIANCE/ EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES I -lee.. Permit Fee: Re -Pipe Interior 1PRREPIPE Other Elec. Insp. 1 # $13 Water Service 1BPWSVCS Suppl. Insp Fee 1 # $23 PME Unit Fee: $36.00 PME Permit Fee: $45.00 Construction Tac: Administrative Fee: 1ADMIN $42.00 Work Without Permit? Yes Q No $0.00 TOTALS: y A Travel Documentation Fee: ITRA VDOC $36.00 St, out! Motion Fee: IBSEISWICR NOTE: T his eRintale does not include fees due to other Deparnnents (i.e. Planning, Puhlic 11'orks, Fire, Sanitary Sewer District, School District, etc.). These fees are ha.sed on the prelinninan• information available and are onh, an estintate. Contact the Dent for add n 7 info. FEE ITEMS (Fee Resolution 11-053 E ' 7/1/11) beech. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 Elec. P1un Check beech. Permit Fee: Plumb. Permit Fee: IPPERb11T I -lee.. Permit Fee: Other 'Ifech. Inst). Other Plumb Insp. 0.0 hrs L$45.00 Other Elec. Insp. ,[tech. hup. Fee.: Phunh. lisp. Fee: Etec•. Insp. Fee: NOTE: T his eRintale does not include fees due to other Deparnnents (i.e. Planning, Puhlic 11'orks, Fire, Sanitary Sewer District, School District, etc.). These fees are ha.sed on the prelinninan• information available and are onh, an estintate. Contact the Dent for add n 7 info. FEE ITEMS (Fee Resolution 11-053 E ' 7/1/11) FEE QTY/FEE MISC ITEMS Plum Check Fee: Supp/. PC Fee PME Plan Check: $0.00 Permit fee: Suppl. Insp Fee PME Unit Fee: $36.00 PME Permit Fee: $45.00 Construction Tac: Administrative Fee: 1ADMIN $42.00 Work Without Permit? Yes Q No $0.00 Advanced Planning Fees: y A Travel Documentation Fee: ITRA VDOC $45.00 St, out! Motion Fee: IBSEISWICR $0.58 t Select an Administrative Item 131de Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: $169.58 $0.001TOTAL FEE: $169.58 Revised: 07/01/2012 x GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 G (408) 777-3228 • FAX (408) 7777-3333 • buildinv uDerdno.or UPERTINO Z C-39 U 2- v c� MEP MslNG IVPC'IANI(-AT Irl=Tc=tr?I Irl.. gr,rrswrrnic MISC PR0MCT ADDRESS / I .APN R ( _ /- -�� 0, OWNER NAME 7; (10,I PHONE - E-MAM STREET ADDRESS `( U .J (A IM w11 I CIT, Y. SA IIP / ` ��o U fn N V U w FAX CONTACT NAME I PHONE I :MAC STREET ADDRESS =If, STA _.IIP FAX ,.,� ❑ OWNER ❑ OwNER-B'm ER [3 OW cR AG Y M CO T ACTOR ❑GON aACTORAOEKT ❑ ARCi '_Cf ❑ ENGINEER ❑ DEVELOPER. ❑ VANE CONTRACTOR NA.M'c I L'CENSE NL �i (( ✓ �1� `6(ii I C10E'NS<ME I BLS. LIC p CONOIIY NAME Wlr, (c✓Se� E_ -MAC - miov.u(A44'� e CQ'ri r,h, FAX -�sv-h STREETADDRESS �I ( cr'r. sTA �:c-Y1 I'Q✓U �'^-eW ti c PP�or 1 �7 - l 7 / y ARC:iR'zC-1/ENGLN= NAME / I LICENSE NUMBER / I BUS. LIC P COMPANY NAME' I E -MAC I FAX STREET ADDRESS I C,<., STATZ3 I PHONE USE OF ria m DUPLEX ❑ MULTI-FANGLY PRORtCT IN WILDLAND ❑ YES PROJECT NI ❑ YES BUILONG: ❑ coM . CV,L 11R9AiN INTERFACE nREA ❑ NO FLOOD ZONE ❑ NO SThT_BLDGAN ❑ YES I EtC - Homm ❑ NO DESCRIPTION OF WORK Y e 1 '0 t (V �� pl qq / f— z l N" L? Ila TOTALVALUAMN.. \ (�1� 1 I RECEIVEDBY: By my signan:r_ below, I certify to each of the :ol!mv:gig; I am the pmpery owner, or au:hor'ud agent to ac: on :be prope-y owner's behalf i have read this application and the information I have provided is mr_CL I have read the Desmpdon of Work and verify it is acet=am. I ague to comply with all applicable local ordinances and sate laws rola:irg.tp building co N ,. cti I au[horze r_pmsr.-carves of CaoeTanc :c cnLr ,lc above.id=dficdpmpe.—.1 :or inspection pu doses. � �)�� fig} ' Sigaatum of Applicant/Agean Y�///1^J"'l Date: � MY SUPPLENEENT.^.L TNFOR-kLATi0N REQLRD OFFICE USE ONLY m U V a ❑ OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ NWOR A4EPMLac4pp_1011.coc revised 06/=1111