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09100170 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10293 JUDY AVE CONTRACTOR:PRO ROOTER PERMIT NO:09100170 OWNER'S NAME: SIDNEY WEBER 438 SAN LEANDRO BLVD DATE ISSUED: 10/26/2009 l 3R'S PHONE: 4082552434 SAN LEANDRO,CA 94577 PHONE NO:(510)670-1115 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class 1�_ Lic.# MECH f— RESIDENTIAL r— COMMERCIAL Contractor d cr Date I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL PROPERTY LINE CLEAN OUT IN MAIN (commencing with Section 7000)of Division 3 of the Business&Professions SEWER LINE 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:$1800 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 APN Number:37508045.00 Occupancy Type: permit is issued. 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 ST#RTED 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 ISSU CE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED 15` CION. 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 bte'C 2 9.18. Xti, it Signatur Date R ROS: All roofs shall be ins ected r.' to n material beim installed.If a roof is Cl OWNER-BUILDER DECLARATION p Pte' '.•� g g installed without first obt ring an:-nsp*ion,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 stricture 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. 1 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. Health&Safety Code,Sections 25505,25533,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 Owne r sut riz d a Compensation laws of California. If,after making this certificate of exemption,I � � J�A4Date-Z�_ <5'15�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.) 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 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37508045. 00 DATE ISSUED. . . . . . . : 10/26/2009 RECEIPT #. . . . . . . . . BS000009036 REFERENCE ID # . . . : 09100170 SITE ADDRESS . . . . . : 10293 JUDY AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER SIDNEY WEBER ADDRESS 10293 JUDY AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PRO ROOTER CONTRACTOR JIN OH DBA PRO ROOTER INC LIC # 24097 COMPANY . . . . . . . . . . : PRO ROOTER ADDRESS 438 SAN LEANDRO BLVD CITY/STATE/ZIP . . . : SAN LEANDRO, CA 94577 TELEPHONE (510) 670-1115 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 800 . 00 1 .00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 1, 800. 00 0 .50 0. 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRSEWER UNITS 1. 00 21 . 00 0 . 00 21. 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 106 .50 0 . 00 106 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 106 .50 --------------- TOTAL RECEIPT 106 .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 APN# � -7� � r � , /�L �� Date: Building Address: ^ Q Owner's Name: Phone# iJO ) :25 Contractor: Phone#: \ Fax #: Contact: v Phone#: �) -7b5--C") y7 Fax#: Contractor License#: 36 &E'-Z- Cupertino Z- Cu ertino Business License#: -p Job Description: grt�7z Jf f I Residential Commercial ❑ Valuation: Project Size: ExpressY----Standard Large 0 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 1 PGASCOM 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 CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT (' Fee TYPES 1BSEISMICR Seismic Residential P 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 1 BPGAS Gas Piping System 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B M.Indoor Air Quality and Finishes 1.UO Laili lo-VOC Paint, 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y--yes 0 3 LoM 4Dw 3IAQ/HealthY P is =Y es 0 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y=yes p 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 1"- tr 41AQ/Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0 11 1 N.Flooring LO 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0 1 i 1 Total Points Available: 140 1301 77 Total Points Project Received: 01 0 —0� G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal212.04protected.xis Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF �:UPEI�TINO Fax(408)777-3333 Building Department JOB ADDRESS: PERMIT OWNER'S NAME: ° PHONE # GENERAL CONTRACTOR: FAX # 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