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11100090CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10201 STONYDALE DR CONTRACTOR: T PERMIT NO: 11100090 OWNER'S NAME: JOSEPH WILSON �� , f` DATE ISSUED: 10/12/2011 OWNER'S PHONE: 4087397792 L LICENSED CONTRACTOR'S DECLARATION License Class CLic. # 92i72� Contractor Date 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: 1 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. 1 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. APPLICANT CERTIFICATION 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 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 41 Signature Date %b—/Z— tl OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 permit is issued. 1 certify that in the performance of the work for which this permit is issued, I 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, c^ and expenses which may accrue against said City in consequence of the I ag of this permit. Additionally, the applicant understands and will comply wnu all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date PHONE NO: BUILDING PERMIT INFO: BLDG ELECT f— PLUMB r— MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: INSTALL PROPERTY LINE CLEAN OUT. Sq. Ft Floor Area: APN Number: 32637019.00 Type: PERMIT EXPIRE&!KLI IS NOT STARTED WITHIN 180 DAY IT ISSUANCE OR 180 DAYS FROED INSPECTION. Issued Date: / /Z __ RE -ROOFS: 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: / 7 Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of mrk's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed CUPERTINO GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 950143255 misc (408) 777-3228 • FAX (408) 777-3333 • building ,cupertino.orq `PLUMBING FIN ANicAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS if�<i.1Y' \ OWNER NAME C ^ ' I O� PHO '(0� _29—WLI E-MAIL STREET ADDRESS l TG'�l K� I SC STATE, ZIP FAX CONTACT NAMEPHONE. � 2Gi��oi� yf.& E-MAII STREET ADDRESS :� _ Q d �-�tWor;• {�.. Cnn (. ATE Z1r A_ C4•. O v q Sinn � F� �i °&� � `/ 7 (& 4. fT OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME �nCC-'� ZtiMa�9 LICENSE ER ca -77 2- ' LICENSE TYPE BUS. LIC # COMPANY NAME /t/lCt f C jU(Vj r l� M4�YIvMl�. !�G,n ; �Si 1,/'✓MP. nS uS FAX STREET ADDRESSSCfLA C S .J\ CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COMPANY NAME ' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE JSE OF SFD or DUPLEX ❑ MULTI-FAmmy BUI .DING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: 2 gyp_ C RECEIVED BY: By my signature below, I certify to each of the foIlowing: I am the property owner or authorized agent to act on the pro owner's behalf. I have read this application and the information I have rovided is correct j 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 ilding construction` I authorize representatives of Cupertino to enter the above -identified property for inspection poses. Signature of Apphcant/Agent� � �� -- Date: �� ^ �2 --- / SUPPLEMENTAL INFORMATION REQUIRED OF USE ONLY Y U W U ❑ OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO 1VlF F FCTIMATnR _ RITILDING DIVISION LiADDRESS: 102011 st/onydale dr. DATE: 10/12/2011 REVIEWED BY: bobs. UNITS APN:3�(t!p'. /`(�� BP#: �DQ� "VALUATION: $3,200 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: # PENTAMATION 1 RPSS PERMIT TYPE: woRK install property line clean out SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $22 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 TOTALS: A Travel Documentation Fee: ITRA VDOC $22.00 StronP Motion Fee: IBSEISMICR Plumb. Plan Check 10.0 1 hrs $0.00 Plumb. Permit Fee: IPPERMIT _ Other Plumb Insp. 1 0.0 1 hrs 1 $44.00 - NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public worirs, ,tire, ,anuarynewer utstrict, acnoot L_.... -a .. •L.. .. ..:t.././n -4 Oro -1,, nn ocam"ia C'nnfnrf fho Dont far addn't inia_ FEE ITEMS O ee Resolution 11-053 Etf. 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? 0 Yes 0 No $0.00 A Travel Documentation Fee: ITRA VDOC $44.00 StronP Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $152.50 $0.00 TOTAL FEE: $152.50 Revised: 10/01/2011 7 ITEMS OF 8 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32637019.00 DATE ISSUED.......: 10/12/2011 RECEIPT #.........: BS000015031 REFERENCE ID # ...: 11100090 SITE ADDRESS .....: 10201 STONYDALE DR SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER ............: JOSEPH WILSON ADDRESS ..........: 10201 STONYDALE DR CITY/STATE/ZIP ...: CUPERTINO CA, 95014-1029 RECEIVED FROM ....: IGNACIO ZAMORA 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 3,200.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 3,200.00 0.50 0.00 0.50 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 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 ---------- 267.50 ---------- 0.00 ---------- 267.50 ---------- 0.00 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL ;UPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: I 62c-, t �` c��V�� f'L� PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR: �� ;4 c�` ` ZG� �; BUSINESS LICENSE # ADDRESS: LS -S Laic ojc CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino nusmess ncense. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS 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: Owner / Contractor Signature Date 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