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11070228 z CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10565 SAN LEANDRO AVE CONTRACTOR- PERMIT NO: 11070228 OWNER'S NAME: ANTHONY MONTEFUSCO&LISA BACKUS U►` L �- DATE ISSUED:07/29/2011 OWNER'S PHONE: 4155096767 PHONE NO: G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.# ql��4 Z-7 n MECH r RESIDENTIAL COMMERCIAL Contractd �C �i� � Date l l I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:BACKFLOW DEVICE&PROPERTY LINE CLEAN OUT (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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$300 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35705058.00 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 upon the above mentioned property for inspection purposes. (We)agree to save STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, Q S IS ANCE OR costs,and expenses which may accrue against said City in consequence of the A R CA E1J INSPECTION. 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. Issued by: Date: Signatu Date 2,� �29 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 declarations: HAZARDOUS MATERIALS DISCLOSURE 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 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 Own ed a nt: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 4 ! / 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, v - and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ng of this permit.Additionally,the applicant understands and will comply wan 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 FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10565 san leandro DATE: 07/29/2011 REVIEWED BY: bobs. APN: BP#: EVALUATION: $300 "PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK backflow device and property line clean out. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $22 TOTALS: $22.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $44.00 NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn7 info. FEE ITEMS (Fee Resolution 11-053 f,,'I ,','f.-I1) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A StronmMotion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 ]ADMIN SUBTOTALS: $111.50 $41.00 TOTAL FEE: $152.50 Revised: 07/04/2011 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35705058 . 00 DATE ISSUED. . . . . . . : 07/29/2011 RECEIPT #. . . . . . . . . : BS000014252 REFERENCE ID # . . . : 11070228 SITE ADDRESS . . . . . : 10565 SAN LEANDRO AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : ANTHONY MONTEFUSCO & LISA BACK ADDRESS . . . . . . . . . . : 10565 SAN LEANDRO AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2701 RECEIVED FROM . . . . : PROCON CONSULTING 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 300 . 00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 300 .00 0.50 0. 00 0 .50 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 152.50 0.00 152 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 152 .50 #20172 --------------- TOTAL RECEIPT 152 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: nG1 PERMIT# OWNER'S NAME: t rj-,71_5 Lt) PHONE # 3 C GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: 5(o( CITY/ZIPCODE: 5 *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) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: - 2 % — nature Da e 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 L 1 v7 a Zz g GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 950143255 CUPERTINO (408)777-3228• FAX(408)777-3333• building(ccuoertinc.crq MISC PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS V / n APN# 2 C —7 5 OWNER NAME 021ho ff�10*f� PHO E-MAIL STREET ADDRESS FAX CONTACT NAME /_� MAIL,fa��rf:Z?1 r / STREET ADDRE7 /, T TE, FAX /v a ❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT XZONTRACI'OR ❑CONTRACI'ORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMED, � o' LICEN5 NUMBER L E BUS.LIC COMPANY NAMENLqrCG J ///)G �I, ` l/ E-MAIL FAX STREET ADDRESS ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF ❑SFD or 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 r 0 / 11A 6, TOTAL VALUATION: ( U RECEIVED BY: U By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the perty owner's behalf. I have read this application and the information I have provided is correct.,.I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatingf Cupertino to enter the above-id tified pr perry for inspection pu3poses. Signature of Applicant/Agent: Date: m2Ei= SUPNTAL INF-RMATION REQUIRED OFFICE USE ONLY m ❑ OVER-THE-COUNTER c ❑ EXPRESS Y U w ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06121/11