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11080170 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1673 GALWAY DR CONTRACTOR:ARROYO PLUMBING AND PERMIT NO: 11080170 DRAIN,INC OWNER'S NAME: KEENLY RICHARD R AND CYNTHIA A 650 LINCOLN AVE STE D DATE ISSUED:08/23/2011 iER'S PHONE: 4082064573 SAN JOSE,CA 95126 PHONE NO:(408)278-0170 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT f— PLUMB r— License Class �'3 b Lic.# � 3 3 S D �" rMECH RESIDENTIAL COMMERCIAL Contractor Date Z T I I hereby affirm that I am licsed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL GAS LINE FOR NEW STOVE TOP (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 rr 4 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.Ft Floor Area: Valuation:$1000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36624028.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. dditionally,the applicant,u rs ands and will comply with all non-point so ce regulations per he Cupertino nicipal Code,Section 9.18. Issued by: Date: �� Signature Date )1 L, OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law 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 Applicant: 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 I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 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 Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)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 permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will maintain compli ce with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safe Code,S/chon 25505. 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 exemption,I Owner or tt orized'g become subject to the Worker's Compensation provisions of the Labor Code,I must Date: Zs forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this 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 inify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply 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 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36624028 . 00 DATE ISSUED. . . . . . . : 08/23/2011 RECEIPT #. . . . . . . . . : BS000014534 REFERENCE ID # . . . : 11080170 SITE ADDRESS . . . . . : 1673 GALWAY DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : KEENLY RICHARD R AND CYNTHIA A ADDRESS . . . . . . . . . . : 1673 GALWAY DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5240 RECEIVED FROM . . . . : ARROYO PLUMBING & D CONTRACTOR . . . . . . . : MATTHEW PATRICK LIC # 32322 COMPANY . . . . . . . . . . : ARROYO PLUMBING AND DRAIN, INC ADDRESS . . . . . . . . . . : 650 LINCOLN AVE STE D CITY/STATE/ZIP . . . : SAN JOSE, CA 95126 TELEPHONE . . . . . . . . : (408) 278-0170 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 1, 000 .00 1. 00 0. 00 1 . 00 0. 00 1BSEISMICR VALUATION 1, 000 .00 0.50 0. 00 0 .50 0. 00 1PGASRES OUTLETS 1 .00 65. 00 0. 00 65 . 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 195.50 0. 00 195 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 195 . 50 #11590 --------------- TOTAL RECEIPT 195 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING t ( � � oc7a CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 1673 galway dr. DATE: 08/23/2011 REVIEWED BY: bobs. APN: BP#: wVALUATION: j$1,000 '-,PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPGAS USE: PERMIT TYPE: WORK install gas line for new stove top. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $65 TOTALS: $65.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $44.00 LLJ L NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (h' e Resolution I1-053 P ff. TT"]11 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: 1BSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 1ADMIN SUBTOTALS: $154.50 $41.00 TOTAL FEE: $195.50 Revised: 07/04/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTiNO (408)777-3228 • FAX(408)777-3333• building(c.cuDertino.org MISC PLUMBING ❑IvIECHANICAL F]ELECTRICAL ❑MISCELLLLAN�E0UUS PROJECT ADDRESS i3 G A I ��/ APN OWNERNAME PHONE ff E-MAIL To � ,t. f( L14 Ac STREET ADDRESS ty, STATE,ZIP e' n S ; FAX CONTACT NAME PHONE E-MAM STREET ADDRESS CITY,STATE, ZD? FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER >r, � LICENSE TYPE BUS.LIC# P"4--J L--- 3 "3 COMPANY NAME E-MAIL FAX /. f1�ew !� A.,, �} r,~ .4 � J. Ivy,. ✓ -z STREET ADDRESS 1\ CITY,STATE,ZIP , J,(` C �i f\1 PHONED-Z?v b3'� f_�t, )� U J J ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF �G SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIL DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCL4L URBAN INTERFACE AREA -® NO FLOOD ZONE 40 NO EICHLER HOME? NO DESCRIPTION OF WORK TOTAL VALUATION: j .o J 1) RECEIVED BY: By my signature below,I certify to each of the fol}owing: I am the property owner or autl;DFizfd agent to act on the property owner's behalf. I have read this application and the information I have provide 's correct.]have read the Des 'ption of Wo and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin construction. I authorize rep tanves of ertino to enter the abov 'dentif property for inspection pu{poses. Signature of Applicant/Agent: Date: L Z? 1 SUPPLEMENTAL INFORMA N REQUIRED OFFICE USE ONLY OVER-THE-COUNTER ❑ EXPRESS U w ❑ STANDARD U ❑ LARGE ❑ MAJOR AffPMIscApp_2011.doc revised 06121111 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: ) 3 CA PERMIT# ' c% OWNER'S NAME: T;,,, PHONE # 4:,% , 't-% 1- G � } GENERAL CONTRACTOR: An BUSINESS LICENSE# 3 z- 3 =-? ADDRESS: j,S L,� ,t 4. f a ra., )Jf r e A c ' i CITY/ZIPCODE: r4, *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) W L BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUB NTRACTORS AVE O AINED A CITY OF CUPERTINO BUSINESS LICENSE. - k Z.? o 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 7 ` s 3 z. L- Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date