11080006 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10362 TANTAU AVE CONTRACTOR:PENNINGTON PLUMBING PERMIT NO: 11080006
SERVICE
OWNER'S NAME: KADAKIA PARIMAL AND NIKITA 118 E FREMONT AVE DATE ISSUED:08/01/2011
ER'S PHONE: 4087450386 SUNNYVALE,CA 94087 PHONE NO:(408)738-8115
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class �`�� Lic.# � `2' ` l
p� MECH RESIDENTIAL COMMERCIAL
Contractor Venrtt 1 +�i►1 Date O V—D 1' 1 1
I hereby affirm that I am licensed under t e provisions of Chapter 9 JOB DESCRIPTION:INSTALLATION OF GAS SHUT VALVE(EMERGENCY)
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect. M/
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:$500
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. APN Number:37508033.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by: Date:
9.18.
Signature 1,44 L Date b �'
RE-ROOFS:
r OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner aut z
Compensation laws of California. If,after making this certificate of exemption,I Date: 69-01-1
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
1 certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
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 I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
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 37508033 . 00
DATE ISSUED. . . . . . . : 08/01/2011
RECEIPT #. . . . . . . . . : BS000014264
REFERENCE ID # . . . : 11080006
SITE ADDRESS . . . . . : 10362 TANTAU AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER KADAKIA PARIMAL AND NIKITA
ADDRESS . . . . . . . . . . : 10362 TANTAU AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RONALD M PENNINGTON
CONTRACTOR . . . . . . . : RON PENNINGTON LIC # 31352
COMPANY . . . . . . . . . . : PENNINGTON PLUMBING SERVICE
ADDRESS . . . . . . . . . . : 118 E FREMONT AVE
CITY/STATE/ZIP . . . : SUNNYVALE, CA 94087
TELEPHONE (408) 738-8115
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 500 . 00 1. 00 0. 00 1. 00 0. 00
1BSEISMICR VALUATION 500 . 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
----------------- --------------- --------------------
CREDIT CARD 195 . 50 VISA
---------------
TOTAL RECEIPT 195 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
506 GAS TEST 507 FINAL PLUMBING
GENERAL PERMIT APPLICATION -_ MEP
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
ELI (408)777-3228 • FAX (408)777-3333 • building(d)..CuoeriinO.Orq misc
CUPERTiNO
PL' ❑YfECF-�MCAL []ELECTRICAL []MISCELLANEOUS
PROJECT ADDRESS t ,�^1�1 A"N' 3-75 0 ,3
OWNER NAME (Z-, 4 ,1 PHONE�N 6y>Q f_ E-MAIL((Yl jJ � V V 1(J
STR.EEi ADDRESS+_ 1 ^ CITY, STATE,� ly�o FAX ~--`
CONTACT NAME � n�<(�d�J IG� PHONE
STREET ADDRESSUZ CITY,STA ZIP Q ��l� FAX �-
❑ OWNER ❑ OWNER-BL-ILDER ❑ OWNERAGENT I CONTRACTOR ❑CONTRACTOR AGENT ❑ ARC:DTECT ❑ENGINEER ❑ DEVELOPER ❑ TINANT
CONTRACTOR NAME 1 LICENSE NUMBER 0"-jq,2 qG LICENSE TYPE BUS.LIC#
coMPArrrN 1'C+11tc 1 av��t11 E Vero', >
S ADDRES CITY,STATE,ZIP
CA) t,�Etz� rt• Z-(3 (L K
ARCHITECT/ENGINt.ER NAME LICENSE NUMBER BUS.L1C#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
JSE OF ❑SFD.DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCLIL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EIC1-=HOME? ❑NO
DESCRIPTION OF WORK t CAP J C S 1
t ,r6 Lo�eaA 0,11c"
i
TOTAL VALUATION: 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 scription of Work and verify it is accurate. I agree to comely with all applicable local
ordinances and state laws relating to builoijg construction'I authorize rpffeseptatives of Cupertino to enter the above-ideppntined property for inspection pud=poses.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
❑ EXPRESS
U
W ❑ STANDARD
U
❑ LARGE
❑ MAJOR
!LIEP1fiscApp_2011.doc revised 00/21111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: 'VALUATION: $500
PERMIT TYPE: Plumbing Permit— �: PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION 1 RPGAS
USE: SFD or Duplex PERMIT TYPE:
WORK
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. 10.0 �hrs $44.00
El
NOTE: These fees are based on the preliminary information available and are onl an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Pee Resolution .I.- F.,ff.' ';'/.-'Il) 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 (j) No $0.00
Travel Documentation Fee: ITRAVDOC $44.00
Strong Motion Fee: 1BSEIS1vffCR $0.50 0.5 hrs Admin./Clerical Fee
Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 IADMIN
SUBTOTALS: $154.50 $41.00 TOTAL FEE: $195.50
Revised: 07/04/2011