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11050022CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21884 WOODBURY DR CONTRACTOR: ABLE SEPTIC PERMIT NO: 11050022 OWNER'S NAME: MARILYN BECK P O BOX 24819 DATE ISSUED: 05/03/2011 OWNER'S PHONE: 4083903452 SAN JOSE, CA 95154 PHONE NO: (408)377-9990 G LICENSED CONTRACTOR'S DECLARATION r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class r Ll Z Lic. # 6 77 4 Luu R COMMERCIAL S— MECH RESIDENTIAL Contractor l�l.�ZF Af.-p TIC _ Date ft I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ABATE SEPTIC TANK, INSTALL NEW SANITARY LINE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. V ereby 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: $7335 1 have and will maintain Worker's Compensation Insurance, as provided for by AE' Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APNmbier 26i 06 0 O u y APPLICANT CERTIFICATION 1 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 regulations the Cupertino Municipal Code, Section r , " with all non -point source per Issued b -�' Date: I by: 9.18. :SLS�e L� Cif Z Date 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: 1, 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) 1, 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 Health & Safety Code, Sections 25505, 25533, and 25534. [ certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Owner or authorize agent;: L �h Compensation laws of California. If, after making this certificate of exemption, I :S;t - P. /"-)— — Dater 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 c(--'- and expenses which may accrue against said City in consequence of the s ig 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 ........: 32619067.00 DATE ISSUED.......: 05/03/2011 RECEIPT #.........: BS000013365 REFERENCE ID # ...: 11050022 SITE ADDRESS .....: 21884 WOODBURY DR SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: MARILYN BECK ADDRESS ..........: 21884 WOODBURY DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014-1148 RECEIVED FROM ....: ABLE CONTRACTOR .......: GILBERT, GLEN LIC # 21407 COMPANY ..........: ABLE SEPTIC ADDRESS ..........: P O BOX 24819 CITY/STATE/ZIP ...: SAN JOSE, CA 95154 TELEPHONE ........: (408)377-9990 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 7,335.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 7,335.00 0.73 0.00 0.73 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 ---------- 145.73 ---------- 0.00 ---------- 145.73 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 145.73 --------------- 145.73 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- #16680 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - building(5cupertino.org 1-56 PLUMBING F- MECHANICAL F I ELECTRICAL F7 MISCELLANEOUS MEP misc PROJECT ADDRESS W oQ Y 1 APN I � I - OWNER NAME r ] t ( � PHO S 390 z E-MAIL STREET ADDRESS r CITY, STATE, ZIP GL , FAX CONTACT NAMEj PHO ©g E-MAIL STREET ADDRESS /Vzo❑ CITY, STATE, e FAX OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMELICENSE NUMBER 7 LICENSE TYPE BUS. LIC Y COMPANY NAME fa 6 L 2:-- 'STREET E-MAIL FAX STREETADDRESS �� D �� CITY, STATE, ZIP , P � � 79 cm ARCHITEC rIENGINEER NAME LICENSE NUMBER BUS. LIC R COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE 'ISE OF ®FD or Duplex STRUCTURE: ❑ Commercial ❑ Multi -Family PROJECT IN WILDLAND URBAN INTERFACE AREA ❑ Yes ❑ No PROJECT IN FLOOD ZONE ❑ Yes ❑ NO DESCRIPTION OF WORK 111A SD© 1). 5e -04JC . ��h k TOTAL VALUATION: 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..�,c � Date: I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent:�C� � � L \ / I- I � � 1 SUPPLEMENTAL INFORMATION REOUIRED . 5 MEPM1.scApp_1011.doc revised 03/16/11 CITY OF CUPERTINO WNW FF F F CTIM A T"R _ RI TTT .11ING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 21884 woodbury dr. DATE: 05/03/2011 REVIEWED BY: bobs. UNITS APN: BP#: "VALUATION: 1$7,335 'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Du lex USE: p # PENTAMATION 1 RPSS PERMIT TYPE: WORK abate septic tank install new sanitary line. EEI SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $21 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes No $0.00 TOTALS: A Travel Documentation Fee: IIRA VDOC $21.00 Strong Motion Fee: 1BSEISMICR 1. d-nntart tho Dont for addn �1 info. FEE ITEMS (hie Resolution 09-051 I tf. 7/1,10) 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 No $0.00 A Travel Documentation Fee: IIRA VDOC $42.00 Strong Motion Fee: 1BSEISMICR $0.73 0.5 hrs Admin./Clerical Fee $39.00 ]ADMIN Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS $106.73 $39.00 TOTAL FEE: $145.73 Revised: 04/29/2011 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: W o Jp J C Y PERMIT # � ��- OWNER'S NAME: PHONE # GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: j0Z0 j?Qq CITY/ZIPCODE: *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: -C L CY U �- s Signature Date Please check applicable subcontractors and complete the following information: s/ 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