12090155 CITY OF CUPERTINO 13UILDING PERMIT
RUII.DINC ADDNF.SS: 209i4 Pf:PPGR TRf;H I.N CON'IRACPOR:ONG DAY COMPLBTG PF.Rp1IT NO: 12090155
asr�re
O��'NEH'S\.\pIF,: SANDRA MURATA 662 N 12TI1 ST D.\7'li ISSUED:09/19/2012
O��'NEN'S�PIIO�F.: 4088383371 SANIOSE,CA 95112 PIIO�ENO:(408)603-0554
_ LICI�\SF.D CONPRACI'OH'S DECI..\RA710\ .IOti DESCRIP"1'ION: RI•:SIDF,NI'I,\I. COD1p1ERCL�L
LicenseClassC� Lic.H1�St��/� COPPERRE-PIPE
Contractor Date '
I here aRrm thn�I am IicenseJ unJrr�he prorisions of Chapler 9
(c imencing�vi�h Scrtion 7000)nf Uicisiun 3 of the Nusincss K Professions
CnJc anJ�hal m}'license is in full force anJ c(keL '
1 hereby uffirm unJcr penalq'of perjun'nne of Ihe follnaing hro declnratinn5:
I havc and will mainmin n ccnificatc of consem Io sclf-insure(or N'orkcr'S
Compenmtian,as providcd for by Secliom3700 of Ihe labor Codc,for the
performnnce of the�eork for which�his permit is issued. Sy.PI Floor Arca: �'aluation:$7500 .
I have and will mainmin Worker's Compensation Insurance,as pmvided for by
Sec�ian 3700 of the L:�bor Codc,for the pcd'ortnance of the��nrA(or which this ��������mbcr:359130J6.00 Occupanq�T}•pe:
permit is issucd.
,U'PLIC.\N"I'CF,R'I'IF'ICA'I'ION
I certi(y thal I hirvc rend�his applicntion imJ sia�e ihnl the abo��e information is pERMIT EXPIRES IF WORK IS NOT STARTED
correcL I ngrcc lo contply with all city nnd county ordi�u�nccs and 51a1e la�cs rclating W�TH1N 180 DAYS OF PERMIT 1SSUANCE OR
10 huilding construction,nnd he¢by authorizc representativcs of this city to enter
upon thc nbove mcntioned propmy for inspcction purposcs. (14e)agree to snve 180 DAYS � LAST CALLED INSPECT[ON.
indemni(y anJ keep hnrmless lhe Ci1y of Cupertino agninsl liabilities,jud�mcnls, /�
costs,and espenses which may accruc ngainst said City in consequence of Ihe �/� �/ �
granting o(this pemiiL Additionally,the upplicant underslmids and e'ill comply �SSued by: Da[e:
w�ilh nll non-point source regula�ions per Ihe Cupertino Municipal Code,Section
9.18.
kE:uooHs:
Signawr atc / � qll roofs shnll be inspecicd prior to any roofing malerial beine ins[alled.If o roo(is
insialled w�ilhout firsi oblaining an inspection,I ogree to remore all new materials for
inspeclion.
o�v�r•.u-ntni.nes neci..�e,cno�
�Signature of Applicant: Datc:
1 hcrcM'uflirm Ihal I vm ezempl hnm�hc Conlroclur's License I.ae'for one nf
�he follmving nra rensons: ,\I,L HOOP COVERINGS TO RE CI„�SS".\"OR BETI'ER
1,az ow'ner of the propeny,or my employccs with wages ns lheir sole mmpensation,
will do the work,und�he struclure is nol imended ar olTered for sale(Sec.70dd,
Business&Professions Codc)
I,as owner of Ihe property,am e�clusively conlmcling�viih licensed cantractors to �������H��OUS\I.\TERI,\IS DISCLOSURE
constnst the projat(SccJ044,f3usincss d Pro(essions Code). I hare reaJ ihc hnznrJnus mnlerinls requiremen�s under Chapter 6.95 of Ihe
Californin Ilcullh S Sufe�y CoJe.Seclions 25505.?5533.and 2553J. 1 will
I hveby a(firm under pcnully of perjury mir nf Ihe fulloa�ing Ihree mninmin cnmpliance a'ilh Ihe Cuperlino�lunicipul Code.Chapter 9.1?and Ihe
declaralions: Ileul�h S Safely Cnde Section?55}2(a)shoulJ I smre or handle hazardous
I have nnd will maintnin a Cenifmn�e of Consenl lo scll-insuce for WorAcr's mn�erial. AJdilionnlly,shoulJ I use cyuipment or de��ices ahich emil harnrdnus
Compensnlion,:tc provided for by Seciion 3700 of the Lubor Code,for the • uir mntnminnnls as JefineJ hy the Bay Area Air Qualih��Ianagemenl Districl 1
pedom�mtCe of IhC wofk(Or which lhi5 permll i5 i55ucd. N'ill main0�in campliancc e'ilh Ihe Cuperlino plunicipal CoJc,Chnp�er 9.12�mJ
1 havc and will nu�imain Workcr's Compcnsmio�t Insur.mcc,az providcd for b}• �hr Ilrnllh 3 Sn@�y Cndc.Scclinns?5505.25533,anJ?5531.
Seclion 3700 o(ihe Lobor Code,for the perfortnance o(the��nrA(or�chich tliis
Oa'ncr or a�nLori'red�aga�r. Dulr:�
pcmtit is issued.
I certify.thal in Ihe performancc of tlu work for which Oiis permit is issued,I shnll
nol cmploy nny person in miy mnnner so ns to hccomc subject lo Ihc N'orAer's
Compensation Imcs of Cnli(omia. If,after making this cenificme of e<emp�ion,I CO�S"1'RUCI'ION LI?NDINC AGE\C\'
become subjecl to tlie R'orker's Compensation provision5 of the Labor Code,I must 1 hereby amrm that there is a conslruction Irnding agency for ihe per(ormance of
forthw�i�h comply with such pravisions or this permit shall be decmeJ re��oAed. ��'orA's for w�hich�his permit is issucd(Sca�3097,Civ C.)
LrnJcr's\nmc
,\I'PIJCA�I'CF.R7lFICA'I�ION LcnJePSAddress
I ceni(y Ihat 1 hm�e read this applicalion ond state�hat the aboae infortnation is �
wrrecl. I agrte ta comply wi�h all cily and counry•ordinances and stam la�cs relating
lo building conslruction,nnd hercby aulhoriu representatives of this ci�y to enter
upon�he abo��e mentioned property for inspcc�ion purposes.(�4'e)asree Io sarc ,\RCII I'I'F.CI"S DF.CLARATIO\
indemnify and kcep harmlas the City of Cupenino againsl liabilities,judgmcnts,
cos�t,and e�penses u�hich may nccrue agains�said Ciiy in consequence of the I understnnd my plans shall be used as public records.
gmnling of ihis permil.Addi�ionally,lhc applicant understands and will comply
with all non-poim sourcc mgulations per thc Cupenino Municipal Code,Section Licensed Professionnl
9.18.
Signaturc Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUICDING DIVISION
. 70300 TORRE AVENUE�• CUPERTINO, CA 950143255 � M I S C
CUPERTINO (408)777-3228 • FAX(408)777-3333 • buildina(c�cuoerino.orq�
PLUMBING ❑MECYaNICAL. ❑ELEC7RIfA1 Q�fISCELL.4NE0U5 IC/ v / � IS�'
PAOIECI'ADDRES� AW� �/ 1 . I J !'1 I ( n
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OWiJERN �� PHONE J � E-I.fA11
STREE7�RESS ^� / �- m��re.z8 FAX
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CONTACT NAME . PHONE C E�FWL �
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❑OWNER ❑ OWNER�BUIlDpt ❑ ONT'EqAGENf �tUKIIUCIVR ❑[ONTMCTORAGIIff ❑ MCFIITELT ❑ENGINEflt ❑ DEVEIDPFR ❑ TENnNi
CAMMCI'ORN E LICENS � LICENSETYPE f _ 8[1S.LICN
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CAMPANY NA.ME ` E-MAfL ' FAX
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AACHTcL7/ENGINEER NNAE LICENSE NUhfHE1t ,HUS.LI[i
COMPANYNMfE' I E-1+NIl. FAX
STREEC ADDRESS I CI'[Y,STe1TE,L[P � PHONE
USE OF FD w DI/PLEJC ❑ MUI.TI-FAhID.Y PROJECT W w'RDUND ❑ YES I PROIECT�N ❑YES IS Tl{E BLDG nN ❑ YES
BUtIDPIG: �COM1L�fERCIAL UItHqN pJTERFACE aAF.� NO FL00�ZONE 0 �CFfl.ER HOME' NO
DESCRIDTION OF WORIC \ '
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TOiAL`/ALUATION: RECEIVEO BY: G�1.�
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By my signattve be ow,t ccrcify to wch of che following: i am[kie pmpe:ty owner or authorized agrnt ro act on the property owner's behalf I havc rcad this
application and che infortnatiom[fiave pmvided is cor.ect. f have rwd Ihe Ducription of Wotk and verify i[is accurnte. I agree�o camply with alI applicable local
ordinancu and stam laws mlating� 'Iding conswc' au ' e m entznves of Cupertinu to cnter[he above-ideneified'propery. for inspecrion puiposu.
SignatuleofApplicanr/Agen Da[e: '
SUPPLEMENi'P.L.•INFOR�UITION REQUIRED OFFICE USEONLY
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h1EP�Yfuc4pp_1011.doc revired 06/31/JI -
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20954 Pepper Tree Ln DATE: 09/19I2012 REVIE�1'ED BY.: Sean
� ppy; gpy; 'VALUATION: $7,500
*PERDIIT'T'Yve: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRNIARI' SFD Of DU 18x PEYTANATION �RPRP
USE: p PERMITTI'PE: �
�vORK Re i e entire existin residence with co er i in .
SCOPE
APPLIANCE/EQUIP Tl'PE FEE ID QTl' UNITS BP FEES
Re-Pipe Interior 1PRREPIPE 1 # $13
TOTA LS: $13.00
bl:•ch.Plan C"heck Plumb. Plan Check 0.0 hrs $0.00 £lec. Plmi Chrck
,Nec%. Pennir Fee: Plumb. Permit Fee: /PPERdI/T f:(ec. Perniii Fre:
Orhm�dfech. lnsp. Other Plumb Insp. 0.0 hrs $45.00 Od�er E(er.lii.vp.
A�/ecG.btip. Fee: Phmrb. Gixp. F�•t: E(ec bup. l�r.c:
A'OTE: This estimate doc.c imt inchide jeer due�o aher Deparnne�u.r(i.e. Plaiining, Pub/ic IVnrks, Fire,Snnitnq�Sewer Distric�,Sc/mol
Distric�, etcJ. Tl�ese ees nre hnseAnn�he reliminnm in onnn�inn m�nifrshle nnd are onlv nn es�iinnte. Canmc��He De t ar addn'l ix o.
FEE ITEMS (Fee 2e.rohnion I l-Oi3 E/1 7/l/ll) FEE QTY/EEE MISC ITEMS
Plun Check Fee:
S�q�pl. PC Fee
PME Plan Check: $0.00
Penni� Fec::
Suppl. lnsp Fee
PME Unit Fee: $13.00
PME Permit Fee: $45.00
Consnvcfiorv To.�:
Administrative Fee: I.�DAt1,Y $42.00
Work Without Permit? � Yes � No $0.00
Advai�ced Plun�iing Fees:
Travel Documen[ation Fee: ITR.n'DOC $45.00 �
Sirone Motion Fee: IBSf:ISAliCR $0.75 Select an Administrative Item
131de Stds Commission Pcc: IBCeSC $1.00
SUBTOTALS: $146.75 $0.00 TOTAL FEE: $146.75
Revised: 07IOt12012