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11050292 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6165 SHADYGROVE DR CONTRACTOR:BELL PLUMBING SOUTH PERMIT NO: 11050292 BAY OWNER'S NAME: RAHUL PANDIT 3710 YALE WAY DATE ISSUED:05/31/2011 "ER'S PHONE: 4083851206 FREMONT,CA 94538 PHONE NO:(408)279-8824 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class G "0 G Li,.# O''�c� 1 r t _ MECH RESIDENTIAL COMMERCIAL Contractorp�vsb:v► ate I hereby affirm that I am licensed under the provisions o Chapter 9 JOB DESCRIPTION:MAIN SEWER LINE REPLACEMENT FROM HOUSE TO (commencing with Section 7000)of Division 3 of the Business&Professions PROPERTY LINE 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 whi h t/hiiss permit is issued. t/,1. Sq.Ft Floor Area: Valuation:$4100 APPLICANT CERTIFICATION C` I certify that I have read this application and state that the above information is APN Number:37540014.00 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 this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations p the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. C Signature '— Date � 3l / Issued b;— Date: 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain [have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined 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 compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,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 or authoriz agent: fwd Date: APPLICANT CERTIFICATION 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 affirm that there is a construction lending agency for the performance of"ork'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 i-'-mnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the Lender's Address gating 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 -1 2- GENERAL GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•building(a)cupertino.org MISIC CUPERTINO PLUMBING MECHANICAL ELECTRICAL MISCELLANEOUS PROJECT ADDRESS 6 1,6 rll,(, -fir j1 APN# OWNER NAME 1 / P /,,f— �►�/ PHONE /1U J ^�O p� / E-MAIL GtiILLG�I �aw I / t7 J STREET ADDRESS //� S /Q C r,yG �l✓� CITY, STATE,ZIP � FAX CONTACT NAME (�! /'I e 4J PHONE E-MAIl, STREET ADDRESS CITY,STATE,ZIP FAX [;� OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME ( t ICE S4 NUMBER�� LICENSE TYPE Z BUS.LIC# ,,3a COMPANY NAME E-MAIL 76 `J FAX STREET ADDRESS CITY,STATE,ZIP PHONE rya mol/ G j•- • � �> - ARCHITECT/ENGINEER NAME LICENSE NUMBER '5l/ Z BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF Dor Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK r s c e� � Y� �G� ,C✓I i2�t V11- Alt-e- 1 TOTAL VALUATION: RECEIVED BY: eff !OD " 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 d the�scrl Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building cons ion. I a orize repen of Cupertino to enter the above-ident' red pro for inspection purposes. Signature of Applicant/Agent: U✓ Date: �l SUPPL EN AL INFORMATION IYQUIRED OFFICE USE ONLY pWp VER-THE-COUNTER F ❑ EXPRESS ❑ STANDARD ❑ LARGE a ❑ MAJOR MEPMiscApp_201 1.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION II[ADDRESS: 6165 shadygrove st. DATE: 05/31/2011 REVIEWED BY: bobs. PN: BP#: "VALUATION: $4,000 r°PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY —7SFD or Du lex PENTAMATION 1 RPSS USE: p PERMIT TYPE: WORK replace sewer line add property line clean out. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Building 1PRSEWER 1 # $21 TOTALS: $21.00 77 Plumb.Plan Check 0.0 Frs $0.00 71 Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. 0.0 hrs $42.00 LLJ NOTE: Theseees are based on the reliminar in ormation available and are onlyan estimate. Contact the De t or addn'1 info. FEE ITEMS (P'ee Resolution 09-051 EfL 11,10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? C Yes No $0.00 Travel Documentation Fee: 1IRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: 1BCBSC $1.00 $39.00 ]ADMIN SUBTOTALS: $106.501 $39.00 TOTAL FEE: $145.50 Revised: 04/29/2011 CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37540014 . 00 DATE ISSUED. . . . . . . : 05/31/2011 RECEIPT #. . . . . . . . . BS000013606 REFERENCE ID # . . . : 11050292 SITE ADDRESS 6165 SHADYGROVE DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER RAHUL PANDIT ADDRESS 6165 SHADYGROVE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : BELL PLUMBING SOUTH CONTRACTOR PETER DUMLAO LIC # 26329 COMPANY BELL PLUMBING SOUTH BAY ADDRESS 3710 YALE WAY CITY/STATE/ZIP . . . : FREMONT, CA 94538 TELEPHONE (408) 279-8824 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, 100 .00 1. 00 0. 00 1.00 0. 00 1BSEISMICR VALUATION 4, 100. 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING 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: cS�-. PERMIT# Z f- — OWNER'S NAME: C ALJ '� PHONE# 4P --50 cl GENERAL CONTRAC OR: i ri c BUSINESS LICENSE# 41q6 �-- t ADDRESS: M50 r. 12 CITY/ZIPCODE: o C•A 4�Arl2 *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 H OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. p•r� 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