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11050069 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10546 GASCOIGNE DR CONTRACTOR:SAN JOSE PLUMBING INC PERMIT NO: 11050069 OWNER'S NAME: JUDITH MALONE 19970 MCKEAN RD DATE ISSUED:05/11/2011 OWNER'S PHONE: 4082522245 SAN JOSE,CA 95120 PHONE NO:(408)296-1820 L. LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C 36 – Lie.# /��.S (� MECH RESIDENTIAL COMMERCIAL Contractor S a ti S�o f_,P_ P/,ate�ihg Date�T I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE 40'SEWER LINE ADD PROPERTY LINE CLEAN (commencing with Section 7000)of Division 3 of the Business&Professions OUT,ADD ADDITIONAL CLEAN OUT AT BUILDING 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 Sq.Ft Floor Area: 10$�6250 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:37 008.00 � Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above info at 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. Additionally,the applicant understands and will comply with all non-point sour a regulations per the Cupertino Municipal Code,Section / C, 9.18. // Issued by: a''i"'� Date: Signature Date y OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I 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 I 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. 1 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(x)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 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 1 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 Compensation laws of California. If,after making this certificate of exemption,I Owr) or au �orized * . become subject to the Worker's Compensation provisions of the Labor Code,I must f Date: Ls _LL If 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, co— and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION f. ig of this permit.Additionally,the applicant understands and will comply M..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 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37523008. 00 DATE ISSUED. . . . . . . : 05/11/2011 RECEIPT #. . . . . . . . . BS000013424 REFERENCE ID # . . . : 11050069 SITE ADDRESS . . . . . : 10546 GASCOIGNE DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER JUDITH MALONE ADDRESS . . . . . . . . . . : 10546 GASCOIGNE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SAN JOSE PLUMBING CONTRACTOR GARZA, KEVIN N LIC # 14200 COMPANY SAN JOSE PLUMBING INC ADDRESS 19970 MCKEAN RD CITY/STATE/ZIP . . . : SAN JOSE, CA 95120 TELEPHONE (408) 296-1820 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 6,250 . 00 1.00 0 .00 1 .00 0. 00 1BSEISMICR VALUATION 6, 250.00 0 .63 0 . 00 0 .63 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 145.63 0. 00 145 .63 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 145 .63 #20079 --------------- TOTAL RECEIPT 145.63 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 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•buildingCcDcupertino.org MISC CUPERTINO PLUMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN# 3 U � C PTO . tJ OWNER NAME PHONE E-MAIL a0dj4h C/ Z- Z2"ijS STREET ADDRESS v CITY STATE, n 9 O! FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CTTY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC N COMPANY NAMEE-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE mckeaA Ady� Ck 9S/ -< 2a ARCHTTECTIENOINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF Q-IFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN -MUS : ❑ Commercial URBAN INTERFACE AREA Cl Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK ' -1a CC AQU t L/ ' --ee f C-) e r ox j C&-ah c 1 vi 6AI th-e TOTAL VALUATION: Z S� 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 provide I 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 touilding nstructio �itho e representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant(Agent: - Date: WPL IRD AL INFORMATION REQUE �- _ AiEPM-ucApp-2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION F121 ADDRESS: 10546 gasciogne dr. DATE: 05/11/2011 REVIEWED BY: bobs. APN: I BP#: EVALUATION: 1$6,250 -� "PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Du lex PENTAMATION 1 RPSS USE: p PERMIT TYPE: WORK replace 40' sewer line add property line clean out add additional clean out at building SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $21 TOTALS: $21.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.00 NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 09-051 ] f' 7,'1i10) 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: IIRA VDOC $42.00 Strong Motion l=ee: 1BSEISMICR $0.63 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: IBCBSC $1.00 j $39.00 ]ADMIN SUBTOTALS: $106.631 $39.001 TOTAL FEE: $145.63 Revised: 04/29/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 „U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 4s2�' C —, D PERMIT# 6. 1 OWNER'S NAME: PHONE# ocb L// -LIVE GENERAL CONTRACTOR: p vvt n BUSINESS LICENSE# IS IS to ADDRESS: h r to ?Y1 CITY/ZIPCODE: 9S p 1 ' 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 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 Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date Owner/Contractor Signature