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11040062 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 998 WESTLYNN WAY CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 11040062 OWNER'S NAME: MARIANNE SWENSON 1639 POMONA AVE DATE ISSUED:04/11/2011 Ott' 'S PHONE: 4087395145 SAN JOSE,CA 95110 PHONE NO:(408)2953911 L� LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Li .# (( MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:4-PLEX-(APT 1-4)-REPIPE,CHANGE OUT 25 PLUMBING (commencing with Section 7000)of Division 3 of the Business&Professions FIXTURES,NEW SEWER LINE&CLEAN OUT 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 IR M9X_ Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. pr I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft7nj Valuation:$31000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35927009.00 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. Additional) ,the applicant understands and will comply with all non-point source re Dons r the Cupertino Municipal Code,Section 9.18• / /� Issued by: `� Date: Signatur Date r OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1 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) 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 1 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& 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,S 'ons 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 Owner or nt. rl/1V 4 become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 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, c- - 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 wi.,i 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: 988 westlynn way DATE: 04/11/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$31,000 �'°PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPRP USE: PERMIT TYPE: WORK re i e change out 25 plumbing fixtures new sewer line and clean out SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Re-Pipe Interior 1PRREPIPE 1 # $11 Sewer, Building 1PRSEWER 2 # $42 Fixture or Trap 1BPFIXTURE 25 # $200 TOTALS: $253.00 T-T Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.00 NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (1 ee Resolution 09-051 I ff.'1 b"10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $253.00 PME Permit Fee: $42.00 7_1 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strom Motion Fee: IBSEISMICR $3.10 Select an Administrative Item Bldg,Stds Commission Fee: 1BCBSC $2.00 SUBTOTALS: $342.10 $0.00 TOTAL FEE: $342.10 Revised: 01/15/2011 CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35927009. 00 DATE ISSUED. . . . . . . : 04/11/2011 RECEIPT #. . . . . . . . . : BS000013143 REFERENCE ID # . . . : 11040062 SITE ADDRESS . . . . . : 998 WESTLYNN WAY SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MARIANNE SWENSON ADDRESS . . . . . . . . . . : 998 WESTLYNN WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : WILLIAM D DEMPSTER CONTRACTOR . . . . . . . : WILLIAM DEMPSTER LIC # 31263 COMPANY . . . . . . . . . . : DEMPSTER PLUMBING ADDRESS . . . . . . . . . . : 1639 POMONA AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95110 TELEPHONE . . . . . . . . : (408) 295-3911 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 31, 000 .00 2. 00 0. 00 2 .00 0.00 1BPFIXTURE NO OF FIXTURE 25. 00 200. 00 0. 00 200 .00 0.00 1BSEISMICR VALUATION 31, 000 .00 3 . 10 0. 00 3 .10 0.00 1PPERMITFE FLAT RATE 1.00 42. 00 0. 00 42 . 00 0.00 1PRREPIPE NO OF FIXTURE 1. 00 11. 00 0. 00 11 .00 0.00 1PRSEWER UNITS 2 .00 42 . 00 0. 00 42 .00 0. 00 1TRAVDOC FLAT RATE 1.00 42. 00 0. 00 42 .00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 342 . 10 0. 00 342 .10 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 342 .10 VISA --------------- TOTAL RECEIPT 342 .10 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: -Pe 2,-3y PERMIT# Z OWNER'S NAME: PHONE# GENERAL CONTRACTOR: c „.. BUSINESS LICENSE# ADDRESS: 14 S'�i /V vt CITY/ZIPCODE: :San Fuse *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY I CTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBC N CTO S HAVE OBTAINED A CITY OF CU ERTINO 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 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 La (408)777-3228• FAX(408)777-3333•buildin-g0cupertino.org MISC CUPERTINO PLUMBING,[ ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS ,1 PR JECT ADDRESS APN# T e y�" K h o- 0�%;'{S 1,4 3, 1 OWNER NAME fA I_ '„ ��4,17 e— SLUC�J'Q It) P�d CJ SISI S� E-MAIL STREET ADDRESS V((� 1gT"1,4,tvnte_ STATE,ZIP FAX 122-`9 S^G�w Avr C4 FAX CONTACT NAME ,1 U � ` PHONED STREETAD� ��!? �Z�AZIP /^ 3'�fO FA)C ❑OWNER ❑ OWNER-BUILDER "ER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME �, \` 0 y (oC s LICENSE NUMBER 1�0 LICENSE�J M BUS.LIC# COMPANY NAME N E-MAIL�117417 D�/n S�e.fll �.a FAX STREET ADD,�ESS ✓e- CITY,S�T��Zjr7O_S� C� 957`/0 PHONV.D9 S-7� _S77 14 �a r►+o�v�. .i�',, J ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ISE OF ❑ SFD or Duplex �b ulti-Family PROJECT IN WILDLAND PROJECT IN STRUCTLRE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK JJ__ � v�.s Go @x— �Grv. TI/�C G « �1 O 4�� /?f !J ar<S �L 4 So Re P Ict r C `� INrG%n ��e"Jr.,., ' �-ty'0" e 7 ro.l �a c ,� /c e'f�,. TOTALVALUATION: �QQ RECEIVED BY' � ... 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 Soffect. 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 buildi g c ctio I authorize representatives of Cupertino to enter the above-i ntifi9d property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED t � o� CT 1GfAdOi tVEPMiscApp_2011.doc revised 03/16/11