11060086 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10261 JOHNSON AVE CONTRACTOR:VIP PLUMBING AND PERMIT NO: 11060086
DRAIN CLEANING
OWNER'S NAME: JOHN KNEISL 4020 PAYNE RD DATE ISSUED:06/13/2011
C ',R'S PHONE: 8318834537 PLEASANTON,CA 94588 PHONE NO:(408)644-2288
❑ LICENSED CONTRACTOR'S DECLARATION
/ /- -- BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class V 316 Lic.# -9�63
Contractor
1� '� t+l.,L- Date MECH RESIDENTIAL COMMERCIAL
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE LEAKING 3/4"WATER MAIN LINE BETWEEN
(commencing with Section 7000)of Division 3 of the Business&Professions HOUSE
&WATER METER
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
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$1600
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:37518029.00 Occupancy Type:
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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of thi^permit. Additionagy,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all no -p nt source regulati s per the Cupertino Municipal Code, ection 180 DAYS FROM LAST CALLED INSPECTION.
9.18. 1
SignatureDate 1� Issued by: Date:
L OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,shou)d I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,l shall contaminants a ' efined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain c mp nce with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Healtly-& de,Sections 25505,25533,and 25534.
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. Owner orut �ri agent: lt
Date: ��
APPLICANT CERTIFICATION I CONSTRUCTION LENDING AGENCY
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 I hereby affirlil, that there is a construction lending agency for the performance of Hork's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
in('-^unify and keep harmless the City of Cupertino against liabilities,judgments,
c nd expenses which may accrue against said City in consequence of the Lender's Address
gi,.....ag of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 37518029. 00
DATE ISSUED. . . . . . . : 06/13/2011
RECEIPT #. . . . . . . . . : BS000013732
REFERENCE ID # . . . : 11060086
SITE ADDRESS . . . . . : 10261 JOHNSON AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JOHN KNEISL
ADDRESS 10261 JOHNSON AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JAROSLAW M SKOCZYLA
CONTRACTOR JAROSLAN SKOCZYLAS LIC # 30621
COMPANY VIP PLUMBING AND DRAIN CLEANIN
ADDRESS 4020 PAYNE RD
CITY/STATE/ZIP . . . : PLEASANTON, CA 94588
TELEPHONE . . . . . . . . : (408) 644-2288
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 1, 600. 00 1. 00 0 . 00 1 .00 0. 00
1BPWSVCS WATER SERVICE 1. 00 21. 00 0. 00 21. 00 0 .00
1BSEISMICR VALUATION 1, 600. 00 0.50 0 . 00 0.50 0. 00
1PPERMITFE FLAT RATE 1 .00 42 . 00 0. 00 42 .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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10261 johnson ave DATE: 06/13/2011 REVIEWED BY:
APN: BP#: `VALUATION: 1$1,600
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPWS
USE: PERMIT TYPE:
woRK replace water main
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1BPWSVCS 1 # $21
TOTALS: $21.00
Plumb.Plan Check 0.0 hrs $0.00 -T-T
Plumb.Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 hrs $42.00
NOTE: Theseees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Pe.Resclution 09-051 Lsff T'/,,"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 E) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Strop. Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $106.50 $0.00 TOTAL FEE: $106.50
Revised: 04/29/2011
i ( D ko g�
GENERAL PERMIT APPLICATION _ MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO. CA 95014-3255
(408)777-3228 • FAX(408)777-3333 •building(@,cupertinc.Grg misc
CUPERTINO
X"FLUNMING ❑MECHAMCAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS %�` � l�
OWNERNAME a 1 c;�-� I Z] _7 L�!� E-MAIL
STREETADDRESS �� I✓1 `�'y ,-) I 1 V/ (✓J� G�3 c, FAX
CONTACT NAME / PHONE E-MAIL
STREET ADDRESS CITY.STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ElCONTRACTOR AGENT ❑ ARCHITECT 1:3ENarNM ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME `JA R � / > `�` C�%`�'P BUS.LIC#k Fo/2 '
COMPANY NAME i.�j I �� E N� r '� FAX
STREET ADDRESS
� 1-i_?!a`lO
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC N
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
3E OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE. ❑ Commercial URBAN INTERFACE AREA ❑ Yes Cl No FLOOD zONE ❑ Yes ❑ NO
DESCRIP ION OF WORK 7C�°r LA L L L L c ��' ` — 11 W A M A /A,
TOTAL VALUATION:
By my signature below,I certify to e h the following: I am e;property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I hav vided is correct I ha a rad the Description of Work and verify it is accurate. I a e to mply with all applicable local
ordinances and state laws relating to bui ding �j,uctlon. I th a representatives of Cupertino to enter the above-iden ed p perry for inspection purposes.
Signature of Applicant(AgenC -C% �G � Z - Date:
SU? LEIVIENTAL INF TION REQUIRED
MEFMzscApp j01 L doc revised 03/16/11