11040156CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 18770 NEWSOM AVE I CONTRACTOR: CUPERTINO PLUMBING I PERMIT NO: 11040156 I
i
OWNER'S NAME: DORIS IVEY 11300 DELL AVE STE C 1 DATE ISSUED: 04/21/2011 I
OWNER'S PHONE: 4082523107
L LICENSED CONTRACTOR'S DECLARATION
License Classf Lic. # C. � V 9 O S
Contractor G- A p/ki - Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I eby affirm under penalty of perjury one of the following two declarations:
0periill maintain a certificate of consent to self -insure for Worker's
sation, 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
Section 3700 of the Labor Code, for the performance of the work for which this
perm issued.
APPLICANT CERTIFICATION
ify that I have read this application and state that the above information is
ect. 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
9.18.
Signature V Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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
Compensation laws of California. If, after making this certificate of exemption, I
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.
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
ng of this permit. Additionally, the applicant understands and will comply
w..., all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
CAMPBELL, CA 95008
PHONE NO: (408)253-0618
BUILDING PERMIT INFO: BLDG ELECT F PLUMB r
MECH r RESIDENTIAL
.TOB DESCRIPTION: SEWER MAIN REPLACE
CLEAN OUT
is
Sq. Ft Floor Area: X: Ms Valuation: $4000
{gib
APN Number: 375300Yf'00 } Occupancy Type:
[AL
LINE
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by L �-'_-- - z_ Date:
RE -ROOFS:
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
inspection.
Signature of Appl
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
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
Health & Safety Code, Sections 25505, 25533, and 25534.
Dater c %(
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 37530012.00
DATE ISSUED.......: 04/21/2011
RECEIPT #......... BS000013262
REFERENCE ID # ...: 11040156
SITE ADDRESS .....: 18770 NEWSOM AVE
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER ............. DORIS IVEY
ADDRESS 18770 NEWSOM AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
OPERATOR: patg
COPY # : 1
RECEIVED FROM ....: FRANK L CARDIA
CONTRACTOR CARDIA, FRANK L LIC # 612
COMPANY ..........: CUPERTINO PLUMBING
ADDRESS ..........: 1300 DELL AVE STE C
CITY/STATE/ZIP ...: CAMPBELL, CA 95008
TELEPHONE ........: (408)253-0618
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
----------
NEW BAL
----------
----------
-ADMIN
-------------
HOURS
----------
0.50
----------
39.00
----------
0.00
39.00
0.00
1BCBSC
VALUATION
4,000.00
1.00
0.00
1.00
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
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
----------
145.50
----------
0.00
145.50
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
145.50
---------------
145.50
VOICE ID DESCRIPTION
-------- ----------------------------
106 SEWER & WATER
301 ROUGH PLUMBING
507 FINAL PLUMBING
REFERENCE NUMBER
--------------------
VISA
VOICE ID DESCRIPTION
-------- ----------------------------
202 UNDERFLOOR PLUMBING
400 SEWER/LATERAL
CITY OF CUPERTINO
]RIP V IF gTIM A TnR — RI TILLING DIVISION
191
ADDRESS: 18770 newsom ave.
DATE: 04/21/2011
REVIEWED BY: bobs.
UNITS
APN:
BP#:
"VALUATION: 1$4,000
"PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Du lex7
USE: p
#
PENTAMATION 1RPSS
PERMIT TYPE:
WORK
sewer main re lacment add property line clean out.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Sewer, Building
1PRSEWER
1
#
$21
PME Unit Fee:
$21.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes G No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRA VDOC
$21.00
Strong Motion Fee: IBSEISMICR
Plumb. Plan Check 10.0 1 hrs $0.00MIT
Plumb. Permit Fee: 1PPER
Other Plumb Insp. 1 0.0 1 hrs 1 $42.00 r -
nen rc. IM ,. . f . ,o n 6 .oniI -- }bn nu"MAIo and nro nnhy nn octimnto_ t^nntact the Dent far addn'l info.
FEE ITEMS (Fee Resolution 09-051 1.1j, 7,,'/,,"10)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$21.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes G No
$0.00
A
Travel Documentation Fee: ITRA VDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.50
0.5 hrs Admin./Clerical Fee
$39.00 1ADMIN
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $106.501
$39.00 TOTAL FEE:
$145.50
Revised: 04/01/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
U P E RTI N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: g 1etjSCxr► AXP,
PERMIT #
OWNER'S NAME: t
PHONE # 2. t0?
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS: jQ211 O�Jr L
CITY/ZIPCODE:
*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 SUBCO0 HAVE OBTAINED A CITY OF CUPERTINO
-
BUSINESS LICENSE.
I am not using any subcontractors: U^
Signa ure Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
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
// oLlvl Flo
GENERAL PERMIT APPLICATION MEP
a RA
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO. CA 95014-3255
(408) 777-3228 •FAX (408) 777-3333 • buildinQacupertino.ora
MP
CUPERTINO
r F� PLUMBING FI MECHANICAL ❑ELECTRICAL ❑ MISCELLANEOUS
PROJECa AD �(��
A,1EFMiscApp 201 Ldoc revised 03116/11
-7
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OWNERNAA5.PHONFo�
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E MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
CONTACT NAME
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EMAIL
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STREET ADDRESS
CITY, STATE, ZIP
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❑ OWNER ❑ OWNER-HUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
COCTOR NAME �^ f'. G�'
LIDS£�ru� E O
LICENSE TYPE
BUS. LIC #
COM?r NAME l
E-MAIL
FAX
STREET ADD S S�
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CITY, STATE, ZIr( lti / / �fJ JGUU
(� J
PHOT
ARC=CTIENGINEER NAME
LICENSE NUMBER
BUS. LIC E
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
'JSE OF ❑ SFD or Duplex ❑ Multi -Family
STRUCTURE: ❑ Commercial
PROJECT IN WILDLAND
URBAN INTERRFACE AREA ❑ Yes ❑ No
PROJECT IN
FLOOD ZONE ❑ Yes ❑ No
DESCRIPTION OF WORK
al
TOTAL VALUATION: / G' V U RECEIVJEIBIC }
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. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to 'Iding construction. I autho' senta ' sof Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLE ME 0 TION REQUIRED
A,1EFMiscApp 201 Ldoc revised 03116/11