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11070087 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22821 MEDINA LN CONTRACTOR:DONE RIGHT ROOTER PERMIT NO: 11070087 AND PLUMBING,INC OWNER'S NAME: PONCE ROBERT A AND SCOTT-PONCE 736 CHARCOT AVE DATE ISSUED:07/14/2011 G ' ',R'S PHONE: 4089962046 SAN JOSE,CA 95131 PHONE NO:(408)432-1412 ❑ LICENSED CONTRACTOR'S DECLARATION /3 BUILDING PERMIT INFO: BLDG ELECT' PLUMB License Class G�3� Lic.# �v �` 60 MECH I— RESIDENTIAL COMMERCIAL Contractor p_e T U !1 U 'ICG Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPIPE HOT&COLD WATER LINES IN THE (commencing with Section 7000)of Division 3 of the Business&Professions BATHROOM,INCLUDE 3 ANGLE STOPS Code and that my license is in full force and effect. t4 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 Sq.Ft Floor Area: Valuation:$1500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:34230011.00 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. Additionally,the applicant understands and will comply with all non-point source regulations pe the Cupertino Municipal Code,Section 9.18. ,�// / Issued by: Signature Date n `1 /l G 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. 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, Signature of Applicant: Date: Business&Professions Code) 1,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. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& 1 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 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 I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,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 Ow r or a ri age � , become subject to the Worker's Compensation provisions of the Labor Code,I must T Dater 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 in,' nify and keep harmless the City of Cupertino against liabilities,judgments, a nd expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION graraing 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 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 ELM] Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONT CTOR/ SUBCONTRACTOR LIST JOB ADDRESS: "Z-Z001 PERMIT# /' `7e-,16) OWNER'S NAME: v PHONE# j1-141z GENERAL CONTRACT R: % )CI l ��' BUSINESS LICENSE# '!)Q 17 ADDRESS: -75(,a •,-We 5, a, N CITY/ZIPCODE: *Our municipal code requires all businesses wo ing 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 SUB ONTRACTORS O TAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: - Signature Date Please check applicable subcontractors and complete the following information: V 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 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION MDDRESS: 22821 medina lane DATE: 07/14/2011 REVIEWED BY: bobs. PN: BP#: "VALUATION: 1$1,500 y PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Du lex PENTAMATION 1 RPDP USE: p PERMIT TYPE: WORK re-pipe hot and cold lines at bathroom local includes 3 angle stops, replace sewer drain for shower. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Area 1PREPPIPE 1 # $44 Fixture or Trap 16PFIXTURE 1 # $9 TOTALS: $53.00 Plumb.Plan Check o.01 hrs $0.00 Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. 0.0 hrs $44.00 - Lj NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the Dept for addn7 info, FEE ITEMS (Fee Resolution 11-053 1.& 7-'1.;'11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $53.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: I TRA VDOC $44.00 Strom Motion Fee: 1BSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bld€>Stds Commission Fee: IBCBSC $1.00 $41.00 ]ADMIN SUBTOTALS: $142.50 $41.00 TOTAL FEE: $183.50 Revised: 07/04/2011 i I I k,� 2 _� GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERT{NO a( (408)777-3228• FAX(408)777-3333• building �cupertino.orq MISC LUMBING ELECTRICAL / ��111 MISCELLANEOUS �j _ PROJECT ADDRESS N �J J d�aa kcAPN# UOWNERNAME PHONFq J�iy] E-MAIL STREET ADDRESS Vj��t l / �/JC/ CITY SeTE Z P / CONTACT NAME PHONE E-MAIL STREET ADDRESS / CITY,STATE, ZIP FAX 13 OWNER 13OWNER-BUILDER ❑ OWNER AGENT C� ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME / LICENSE NUMBE /2 /� LICENSE TYP1 Y`/ BUS.LIC# COMPANY NAME �� !MA H �✓`fe�'�C�j f%!6 W& F�UFAX L L et- STREET ADDRESS 13( /i `I� 'Lj� 11 CITY,STATE,ZIP c —j^,J /� PHONE 31 4 3 Z 14/Z. ARCHITECTIENGINEER NAME LICENSE NUMBER / BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF lksv6or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK -i Y12S TOTAL VALUATION: C RECEIVED BY: By my signature below,I certify to each of the following: I am the prope,qy owmer or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided i corr ave r e es 'ption of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating uilding c tr,fctio `I u ori repre tatives of Cupertino to enter the above-identified property for inspection puiposes. Signature of ApplicantJAgent: Date: `/ SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY W 0--OVER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD U ❑ LARGE a ❑ MAJOR AIEPMiscApp_2011.doc revised 06121111