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12100107 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21671 LINDY LN CONTRACTOR:BELL PLUMBING SOUTH PERMITN'O: 12100107 13AY OWNER'S NAME: KLAN DARWIN AND LILLY C TRUSI'BE 1450 KOLL CIR SfE 112 DATE ISSUED; 10/15/2012 OWNER'S PI PONE: 4086051866 SAN,IOSE.CA 95112 PI IONS NO:(408)279-8824 Cl I.10ENS:D C N I'RACI'OR'S DECLARATION r 17 1_! c/&2 1 BUILDING PERDIIT INFO: BLDG ELECT PLUMB License Class ic.k AIECH r RESIDENTIAL C COMMERCIAL r Contractor Q Date ��'� 7 '� 2 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER MAIN REPLACEMENT (commencing with Section 7000)of Division 3 of the Business& Professions Code and(hal my license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a cent fixate of consent to sel Ginsure for Worker's Compensation,as provided for by Section 3700 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 Sq.F( Floor Area: Valuation:$3000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35622017.00 Occupancy Type: APPLIC\NT CERTI FICAT'ION I certify that I have read this application and state that the above information is correct. Iagree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the Cit•of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence ofthe 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source r u]all ms per the per ino Municipal Code,Section _ 9.18. Issued by: V Date�o Signature Dale ��S ❑ OWNER-DUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to my roofing material being installed.If a roof is I hereby affirm that I am exempt from(he Contractor's License lauv for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,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 offered for sale(Sec.7044, Signature of Appli©nC Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATIERLU S 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 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Ilealth&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the I Iealth& I have 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 I use equipment or devices which emit hazardous air contaminants as defined by the Buy Area Air Quality'Management District I will permit is issued maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the I certify(hal in the performance of die work for which this pennit is issued,I shall I leal(h&Safety Code,Sections 25505,25533.and 25534. not employ any person in any manner so as to become subject to the Worker's � Compensation laws of California. If,after making this certificate of cscnmption,l (hyo 'or hor zed agettt� //m_/.�`. become subject to the Worker's Compensation provisions of the Labor Code,I must �/ Do(r C/ Forthwith comply with such provisions or this permit shall be deemed revoked. CONSIRUCI'IIbN LENDING AGENCY \I'I'hIC\Mf CF:RT'IFIC.\T'ION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read(his application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender'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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCH IT ECI"S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35622017. 00 DATE ISSUED. . . . . . . : 10/15/2012 RECEIPT # . . . . . . . . . : BS000018292 REFERENCE ID # . . . : 12100107 SITE ADDRESS . . . . . : 21671 LINDY LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : KUAN DARWIN AND LILLY C TRUSTE ADDRESS . . . . ... . . . . : 13254 PARAMOUNT DR CITY/STATE/ZIP . . . : SARATOGA, CA 95070 RECEIVED FROM . . . . : BELL PLUMBING SOUTH CONTRACTOR . . . . . . . : PETER DUMLAO LIC # 26329 COMPANY . . . . . . . . . . : BELL PLUMBING SOUTH BAY ADDRESS . . . . . . . . . . : 1450 KOLL CIR STE 112 CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE . . . . . . . . : (408) 279-8824 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 .00 42 .00 0. 00 42 .00 0 .00 1BCBSC VALUATION 3, 000 .00 1. 00 0. 00 1 .00 0 .00 1BPWSVCS WATER SERVICE 1. 00 23 . 00 0. 00 23 .00 0. 00 1BSEISMICR VALUATION 3, 000. 00 0. 50 0 . 00 0 .50 0. 00 1PPERMITFE FLAT RATE 1 . 00 45 . 00 0 . 00 45. 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 45 . 00 0 .00 45 . 00 0.00 ------- ------- ---------- ---------- TOTAL PERMIT 156 .50 0. 00 156 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 275 . 50 #2023 --------------- TOTAL RECEIPT 275 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING GENERAL PERMIT APPLICATION Irl E P _ COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 w A (408)777-3228 • FAX (408)777-3333 • building0cuoertino.oro '\aJ' v\ CUPERTINO ❑PLbMBING ❑MECHANICAL / ❑ELECTRICAL ❑MISCELLANEOUS X PROJECT ADDRESS. 7 I 0 L I AN' 6 /1Q ' O [ t (/l O V lf/' p( xOWNERNAME I PHONE /U� ! �/ ..MAIL. 1 v S LEETADDRESSv ` CITY, STATE ZZIP W J b FAX CONTACT NAME PHONE SMALL STREET ADDRESS CITY.STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AOTNT ❑ AR=CT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME �//1 I LICENSENUMBER LCENSE TYPE BUSS..LJCk COMPANY NAME I ✓ _/ I E-MAIL J STREET ADDRESSLL \/` /-��/ C41� CITY.STATE.ZIP ` CSL SLI '2. PHOhi,/'^ ARCHITECT/ENGINEER. AM NAME LICENSE LICENSE NUMBER I BUS.UCH C%D CJ COMPANY NAME' E-MAIL FAX STFEiTADDRESS I CTTY,STATE,ZIP PHONE USE OF ❑SM.DUPIEX ❑ MULTFFAMB.Y PROJECT IN WEDLAND ❑ 1i5 PROJECT IN ❑YES IS THE BLDG AN ❑ Y3 BUILDING: ❑COM ctAt. URBANINTERFACEAREA ❑ NO FLOODZONE ❑NO MCHLZRHOME7 ❑ NO DESCRIPTION OF WORK t Z L G-Q TOTALVALUATION: ocl / I RECEIVED BY: By my signa=e below,I terrify to each of the following: I am:he property owner or amorized agent to act on the property owner's behalf. I have read this application and the information I have provided is corect. I have read the Description of Work and verify it is aceuu-ate. I agree to comply,with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified pmpcml for inspection pu(�oses. - Signanct of ApolicandAgene n Dax: SUPPLEMENTAL MORMATION REQU=D OFFICE USE ONLY ❑ OVER-THE-COUP-TIER ❑ EXPRESS u ❑ STANDARD U ❑ LARGE ❑ MAJOR MEP.VucApp20J Ldoe revised 0621/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 2 ADDRESS: 21671 Lindy Ln DATE: 10/15/2012 REVIEWED BY: jsg APN: BP#: 'VALUATION: $3,000 "PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARI' SFD Of Duplex PENTTTYPE:AIIATION 1RPWS USE: PERMI WORK water main re lacement SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Service 1BPwsvcs 1 # $23 TOTALS: $23.00 tl/ech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elee.I'lan Check Mech. Permit Fee: Plumb. Permit Fee: IPPFRIIIT 61ec•. Permit Fee: Other Mech. Insp. Other Plumb Insp. 0.0 hrs Lnm Otter Flee. Insp. 11e.ch.hop.Fee: Phonb. /n.sp. Fee: Elec.Insp.Fac.• NOTE: This evibnate does toot include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Setter District,School District,etc.). Thesefees are ha.sed on the prelitninarl information availahle and are onh,an estinmte. Contact the De t or ouldn 7 info. FEE ITEMS (Fee Resolution 11-053 ED: 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Sttppl. Insp Fee PME Unit Fee: $23.00 PME Permit Fee: $45.00 Consn•uction Tar: Administrative Fee: MDHIN $42.00 Work Without Permit? O Yes (j) No $0.00 Advanced Planting Fees: Travel Documentation Fee: 1TRdvD0C $45.00 St,rone Motion Fee: IBSFIS,111CR $0.50 Select an Administrative Item 131de Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $156.501 $0.001 TOTAL FEE: $156.50 Revised: 10/01/2012