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11090098 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10055 BYRNE AVE CONTRACTOR:SAN JOSE PLUMBING INC PERMIT NO: 11090098 OWNER'S NAME: MEHUL DHOLAKIA&PRACHI MEHTA 19970 MCKEAN RD DATE ISSUED:09/15/2011 VNER'S PHONE: 4088872135 SAN JOSE,CA 95120 PHONE NO:(408)296-1820 �- LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# J/S-.S/ MECH RESIDENTIAL COMMERCIAL Contractor 0. ate D/—1.S" I hereby affirm that I am license under the provisions of Chapter 9 JOB DESCRIPTION: SINGLE FAMILY DWELLING SEWER REPLACEMENT (commencing with Section 7000)of Division 3 of the Business&Professions INSTALL PROPERTY LINE CLEAN OUT&ADD BACKFLOW DEVICE 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 have and will maintain a certificate of consent to self-insure 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 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$5150 permit is issued. APPLICANT CERTIFICATION APN Number:35711002.00 Occupancy Type: I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT tSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CAL SPECTION. with all non-point sourc regulations per the Cupertino Municipal Code,Section 9.18. ......7 Issued by,. ... ✓,. Date: Signatur Date i OWNER-BUILDER DECLARATION ,a I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior tnlany:_ of material being installed.If a roof is the following two reasons: installed without first obtIng ncc,Y ,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Ap 11'can-, Date: I,as owner of the property,am exclusively contracting with licensed contractors to ' construct the project(Sec.7044,Business&Professions Code). ALL,1104' TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Or uthoreajt.forthwith comply with such provisions or this permit shall be deemed revoked. _Date: l CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the ing of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35711002 . 00 DATE ISSUED. . . . . . . : 09/15/2011 RECEIPT #. . . . . . . . . : BS000014763 REFERENCE ID # . . . : 11090098 SITE ADDRESS . . . . . : 10055 BYRNE AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MEHUL DHOLAKIA & PRACHI MEHTA ADDRESS 10055 BYRNE AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SAN JOSE PLUMBING I CONTRACTOR . . . . . . . : GARZA, KEVIN N LIC # 14200 COMPANY . . . . . . . . . . : SAN JOSE PLUMBING INC ADDRESS . . . . . . . . . . : 19970 MCKEAN RD CITY/STATE/ZIP . . . : SAN JOSE, CA 95120 TELEPHONE (408) 296-1820 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 5, 150 . 00 1 . 00 0. 00 1 . 00 0 . 00 1BSEISMICR VALUATION 5, 150 .00 0. 52 0 . 00 0.52 0 . 00 1PATMOBF UNITS 1 . 00 65 . 00 0 . 00 65 . 00 0. 00 1PPERMITFE FLAT RATE 1 . 00 44 . 00 0. 00 44 .00 0. 00 1PRSEWER UNITS 1 . 00 22 . 00 0. 00 22 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 217. 52 0. 00 217 .52 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 217.52 #20445 --------------- TOTAL RECEIPT 217. 52 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10055 byrne ave. 7DATE: '09/15/2011 REVIEWED BY: APN: BP#: "VALUATION: 1$5,150 r PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: PRIMARY SFD or Du WORK sfd sewer replacement install property line clean out add backflow device. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $22 Vacuum Backflow 1PATMOBF 1 # $65 TOTALS: $87.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. EEhrs $44.00 NOTE. This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.). Theseees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (Fee Resohition 11-053E jf' 'L'11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $87.00 PME Permit Fee: $44.00 Administrative Fee: IADMIN $41.00 Work Without Permit? Q Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: IBSEISMICR $0.52 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $217.52 $0.00 TOTAL FEE: $217.52 Revised: 09/02/2011 oc:9001 �? GENERAL PERMIT APPLICATION MEP ELI] COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildino(a)cupertino.org MISC -ETPI'LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS �� APN# uo-,/ j OWNER NAME . PHO L I / E MAa. 3,; STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHONE E-MAIL STREETADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT .0 CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME / LICEN E NUMBER LICF E BUS.LIC# COMPANY NAME ( E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTIENGINEER NAME ' LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES TF ROJECT IN El YES IS THE BLDG AN El YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO LOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK 6 .5- _ )/ L r Q_c 6 Q J0 P TOTAL VALUATION: +� /J RECEIVED BY: jr - By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provideo is correct. j h e read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to uildin onstruction` o' e representatives of Cupertino to enter the above-identified property for inspection putposes. Signature of Applicant/Agent: ` Date:tLP PL MENTAL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER G ❑ EXPRESS Y U T ❑ STANDARD U ❑ LARGE a ❑ MAJOR MEPMiscApp_2011.doc revised 06/21/11 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Q LAC PERMIT# '' OWNER'S NAME: h PHONE # D�� l 1 "gs8O GENERAL CONTRACTOR: , CLh j u�-'e BUSINESS LICENSE# / ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBC TRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. , `�� 10 p7 /5—/ I Signature L I am not using any subcontractors: ( ' 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 Painting /Wallpaper Paving Plastering t/ Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date