11050013 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1160 ELMSFORD DR CONTRACTOR:JD PLUMBING PERMIT NO: 11050013
OWNER'S NAME: POWER EDWARD R AND MILDRED J 270 UMBARGER RD STE 66 DATE ISSUED:05/03/2011
OAV NER'S PHONE: 4082523538 SAN JOSE,CA 95111 PHONE NO:(408)646-3266
Ci LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r- ELECT PLUMB r
License Class C.�,,p_ Lic.# S�iGr3 MECH r- RESIDENTIAL f— COMMERCIAL
Contractor �� pl�� Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL NEW WATER LINE FROM METER TO SFDWL
(commencing with Section 7000)of Division 3 of the Business&Professions
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:$2000
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:36209012.00 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 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 b "' Date
9.18. y�j
Signature o 1/ " �� Date J //
RE-ROOFS:
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:
I,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).
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. 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
[certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or uthori ed agent.•
Compensation laws of California. If,after making this certificate of exemption,I cL Date:
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
co— and expenses which may accrue against said City in consequence of the
g g of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
w•... 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 . . . . . . . . : 36209012 . 00
DATE ISSUED. . . . . . . : 05/03/2011
RECEIPT #. . . . . . . . . : BS000013355
REFERENCE ID # . . . : 11050013
SITE ADDRESS . . . . . : 1160 ELMSFORD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : POWER EDWARD R AND MILDRED J
ADDRESS . . . . . . . . . . : 1160 ELMSFORD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4950
RECEIVED FROM . . . . : JUAN L DIAZ
CONTRACTOR . . . . . . . : JUAN DIAZ LIC # 30298
COMPANY . . . . . . . . . . : JD PLUMBING
ADDRESS . . . . . . . . . . : 270 UMBARGER RD STE 66
CITY/STATE/ZIP . . . : SAN JOSE, CA 95111
TELEPHONE . . . . . . . . : (408) 646-3266
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 2, 000 .00 1. 00 0. 00 1. 00 0. 00
1BSEISMICR VALUATION 2, 000 .00 0.50 0. 00 0.50 0. 00
1PPERMITFE FLAT RATE 1 .00 42 . 00 0. 00 42 . 00 0.00
1PREPPIPE 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 166 .50 0. 00 166 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 166 .50 VISA
---------------
TOTAL RECEIPT 166 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
506 GAS TEST 507 FINAL PLUMBING
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building(Wcupertino.org MISC
CUPERTINU
LUNMING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS Wo ILLMn2f,7A APN# a6�,2
O /
OWNER NANIE n PHO E-MAIL
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STREET ADDRESS CITY,STA ZIP A FAX
I'y
CONTACT NAME if PHONE E
AA-,7 -MAILArU,
STREET ADDRESS CITY,STATE, ZIP (� FAX
❑OWNER ❑ OWNER-BUILDER Cl OWNER AGENT ACONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBERM 3 LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS �J CITY,STATE,ZIP PHONE
N C/&,IG - a
ARCHPLECTIENGINEERNAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
[STREET ADDRESS CITY,STATE,ZIP PHONE
'SE OF ❑ SFD or Duplex Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE; ❑ Commercial URBAN INTERFACE AREA ❑ Yes No FLOOD ZONE ❑ Yes No
DESCRIPTION OF WORK
L /P-T; E �
_- <;
TOTAL VALUATION: 200(2
OCJ RECEIYCED EES � _ �
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 building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Com. Date:
SUPPLEMENTAL INFORMATION REQUIRED
Y +S
r= �
MEPMiscApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 1160 elmsford dr. DATE: 05/03/2011 REVIEWED BY: bobs.
APN: BP#. "VALUATION: 1$2,000
"PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPDP
USE: PERMIT TYPE:
WORK install new water line from meter to sfd.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Area 1PREPPIPE 1 # $42
TOTALS: $42.00
Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: 1PPERMIT
Other Plumb Insp. 0.0 hrs 1 $42.00
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info,
FEE ITEMS (Pee Resolution 09-051 I.'-I%1 Q) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $42.00
PME Permit Fee: $42.00
Work Without Permit? 0 Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Strom Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee
Bld>,Stds Commission Fee: IBCBSC $1.00 $39.00 1ADMIN
SUBTOTALS: $127.50 $39.00 TOTAL FEE: $166.50
Revised: 04/29/2011
k,Vir IItAk.1"n/ UDk.Vill Ik%.
JOB ADDRESS: 2 PERMIT#,
OWNER'S NAME: s &Z PHONE#
GENERAL CONTRACTOR: ,N BUSINESS LICENSE fr
ADDRESS: 9-70 oe-t ;t 6o,L (zio CITY/ZIPCODE: v�
*Our municipal code requires all businesses working in the city to have a City of Cupertino businesN
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UN _
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERI,.
BUSINESS LICENSE.
I am not using any subcontractors: yl��
Signature Ifate
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