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11100004 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20445 PACIFICA DR CONTRACTOR:+Bf�--zP@'BE PERMIT NO: 11100004 OWN'ER'S NAME: 20445 PACIFICA DENTAL PARTNERS ELIAS LAMBRUS DATE ISSUED: 10/03/2011 VNER'S PHONE: PLUMBINGPHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG � ELECT F PLUMB r License Class Lic.#_ ( C) I— C-- 7 // / /h % MECH RESIDENTIAL COMMERCIAL Contractor rL//J L40,46r&4tDe / _ _) c' JOB DESCRIPTION: INSTALL NEW WATER SERVICE,TO BUILDING I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions 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. Sq.Ft Floor Area: Valuation:$10000 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 permit is issued. !111-v APN Number:36940012.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY OM LAST CALLED INSPE4TON. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the y granting of this permit. Additionally,the applicant understands and will comply Issued by: C JC Date: with all non-point source regulations er the Cupertino Municipal Code,Section 9.18. �� 3 6 r RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection,I agree to remove all new materials for OWNER-BUILDER DECLARATION inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS"I O BE CLASS"A"OR BETTER 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, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal CodAl Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2550 5533,and 25 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent: te: — I certify that in the performance of the work for which this permit is issued,1 shall 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 exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 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 ,�mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM COPY ## 1 Sec : Twp: Rng: Sub: Blk: Lot : APN 36940012 . 00 DATE ISSUED. . . . . . . : 10/03/2011 RECEIPT # . . . . . . . . . : BS000014923 REFERENCE ID # . . . : 11100004 SITE ADDRESS 20445 PACIFICA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER 20445 PACIFICA DENTAL PARTNERS ADDRESS P.O. BOX 8252 CITY/STATE/ZIP . . . : SAN MATEO CA, 94404 RECEIVED FROM . . . . : P.ELIOPOULOUS CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : 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 10, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BPWSVCS WATER SERVICE 1 . 00 22 . 00 0 . 00 22 . 00 0 . 00 1BSEISMICO VALUATION 10, 000 . 00 2 . 10 0 . 00 2 . 10 0 . 00 1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 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 : 269 . 10 0 . 00 269 . 10 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ---------------- --------------- -------------------- CREDIT CARD 269 . 10 MC --------------- TOTAL RECEIPT 269 . 10 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ------------------- -------- ---------------------------- 103 UFER 106 SEWER & WATER 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 20445 Pacifica Dr. DATE: 10/03/2011 REVIEWED BY: gs 0,1APN: BP#: 'VALUATION: j$10,000 '-PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY7SFD or Duplex PENTAMATION USE: PERMIT TYPE: 1 RPWS WORK Install new water service SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Service 1 BPWSVCS 1 # $22 ler n� � � ,"5 el 10 TOTALS: $22.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $44.00 NOTE:This estimate does not include fees due to other Departments 0 a Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prelinina information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (l ee Resohition 11-053 iff 7-1%11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? Yes (E) No $0.00 1 Travel Documentation Fee: ITRAVDOC $44.00 StiOIIQ Motion Fee: 1BSEISMICR $1.00 0.5 hrs Admin./Clerk/al Fee Bldg Stds Commission Fee: IBCBSC $1.00 $4 DMIN SUBTOTALS: $153.00 $41.001 TOTAL FEE: $194.00 Revised: 10/01/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• building(cDcupertinG.org MISC CUPERT[NO t ` I Ob(DOq PLUMBING [I MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN# toy U Of 2 OWNER 2D`i*S Pte► cg E-MAIL Ian 4'A p>} PHONE S .—l i pi COL STREET ADDRESS CITY, STATE,ZIP FAX c� �30 `2-'9 2 Ci-t- CONTACT NAME PHONE E-MAIL STREETADDRESS =,STATE, ZIP FAX ❑OWNER ❑ OwNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NA� m LICENSE NUMBER 5 LICENSE TYPE BUS.LIC#16 COMPANY NAME E-MAIL FAX STREET ADDRESS � Ela -pe � �� CITY STS ZIP C 45 `� PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER L�- BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE 1SE OF ❑SFD r DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: OMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: & Ov RECEIVED BY: 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 provided is correct.,,have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bu' 'ng construc' I authorize representatives of Cupertino to enter the above-identified property for inspection pu(poses. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER a ❑ EXPRESS Y U T ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06/21111 Building Department City Of Cupertino Is 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: " 0415 '�C Y PERMIT# OWNER'S NAME: ,, o, PHONE # - / Z GENERAL CONTRACTOR: BUSINESS LICENSE # 9365 ADDRESS: 3q3n P. CITY/ZIPCODE: S *Our municipal code requires all businesses working in the ity 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 NTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: / < Signature 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 Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date