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09100044 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10528 CHACE DR CONTRACTOR:JA PLUMBING PERMIT NO:09100044 OWNER'S NAME: VENKATESH&USHA NAYAK 28306 INDUSTRIAL BLVD STE B DATE ISSUED: 10/07/2009 ;ER'S PHONE: 4083069046 HAYWARD,CA 94545 PHONE NO:(510)266-5125 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# ��"9 f— (" ,/) l MECH RESIDENTIAL COMMERCIAL Contractor /"7 /�/�sif J`,�7 Date Q I hereby affirmthat 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:COPPER REPIPE FROM METER THRU OUT (commencing with Section 7000)of Division 3 of the Business&Professions HOUSE 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. Sq.Ft Floor Area: Valuation:$4000 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. APN Number:32613082.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.1 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. Signatu/11� Date Z5 / RE-ROOFS: Li 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). 1 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Heal Safety Code,Sections 255 ,25533,and 25534. I 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 "wneru h).r*yed ent-Compensation laws of California. If,after making this certificate of exemption,I / Date: __~�fc 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 constriction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I 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 nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the 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 . . . . . . . . : 32613082 . 00 DATE ISSUED. . . . . . . : 10/07/2009 RECEIPT #. . . . . . . . . : BS000008850 REFERENCE ID # . . . 09100044 SITE ADDRESS . . . . . : 10528 CHACE DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : VENKATESH & USHA NAYAK ADDRESS . . . . . . . . . . : 10528 CHACE DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1010 RECEIVED FROM . . . . : JA PLUMBING CONTRACTOR . . . . . . . : NIGEL EDWARDS LIC # 30554 COMPANY . . . . . . . . . . : JA PLUMBING ADDRESS . . . . . . . . . . : 28306 INDUSTRIAL BLVD STE B CITY/STATE/ZIP . . . : HAYWARD, CA 94545 TELEPHONE . . . . . . . . : (510) 266-5125 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 000 . 00 1 .00 0 .00 1 . 00 0 . 00 1BPWATER UNIT 1 . 00 42 . 00 0. 00 42 . 00 0 . 00 1BSEISMICR VALUATION 4, 000 . 00 0 .50 0 .00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1PRREPIPE NO OF FIXTURE 2 . 00 22 .00 0 . 00 22 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 .00 0 .00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 149 .50 0 . 00 149.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 149 .50 5020 --------------- TOTAL RECEIPT 149 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO " REPIPE/SEWER/MAIN SERVICE CUPEkTiNO PERMIT APPLICATION FORM Ob0 APN# g2 /� b�Z/0(-) Date:�v Building Address: Oer's N e: Phone#: Contractor:,7n U7 VAmk Phone#: Fax#: Contac : Phone ly Fax#: Contractor License#: qlp,,,g,) Cupertino Business License#: Job Description: L Residential Commercial ❑ Valuation:rk ?? Project Size: Express J2 Standard Large ❑ Major❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 -� CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEI,TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 113CBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P I 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1 PLMBINSP Other Plumbing/gas Insp. P / 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B `w Community Development ' 10300 Torre Avenue g Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 „UPEKTINO Building Department JOB ADDRESS: � PE 6 �� lp 9ev OWNER'S NAME: PHONE GENERAL CONTRACTOR: FAX # Ir 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering ✓ Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date