11030018 CTTY ( P CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10823 WILKINSON AVE CONTRACTOR:JD PLUMBING PERMIT NO: 11030018
OWNER'S NAME: CAROLINA& DEITER MUELLER 270 UMBARGER RD STE 66 DATE ISSUED:03/03/2011
1%WNER'S PHONE: 4088651897 SAN JOSE,CA 95111 PHONE NO:(408)646-3266
w e3b. LICENSED CONTRACTOR'S DECLARATIONF
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License CI4 Lic.# f�► � F r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of C pter 9 JOB DESCRIPTION: WATER MAIN REPLACEMENT 60FT FO WATER MAIN W/
lIN
(commencing with Section 7000)of Division 3 of the Business&Professions POLYTHYLENE FROM METER TO ENTRANCE OF HOUSE
Code and that my license is in full force and effect.
1 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:$2160
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 APN Number:35613019.00 Occupancy Type:
permit is issued. &H
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WIT A MIT ISSUANC OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 YS F M LAST LLED INSPEC ION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 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
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534..1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date: 3
I 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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
e,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
.ting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10823 wilkenson ave DATE: 03/03/2011 REVIEWED BY: larry s
APN: BP#: *VALUATION: Iso
R';PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or DuplexPENTAMATION 1 RPWS
USE: PERMIT TYPE:
WORK water main re laement. 60 feet of polyethelene line installed. ground rod hook ed up.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Service 1BPWSVCS 1 # $21
TOTALS: $21.00
L1 1:'a T'Icr:a t ;<(k Plumb.Plan Check 0.0 hrs $0.00 h-R,c a Izpa C`/a.c'c
Plumb.Permit Fee: 1PPERMIT IY mi[f'
Other Plumb Insp. 0.0 hrs $42.00 0,;hur Insp,
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 09-051 El 7:`1,/10) FEE QTY/FEE MISC ITEMS
Man �..�jZfl',ck 1'f'E.'.
r�ZIpp'l. e)t 1'i'iF71
PME Plan Check: $0.00
Pc rll,i i" ,s'a'c.
:`Svpp/. In""11J I'i'i'
PME Unit Fee: $21.00
PME Permit Fee: $42.00
,�cr,tt,ifii:r.11 1��'r•ic=�ti I�cf�:
Work Without Permit? 0 Yes No $0.00
Mannino f
Travel Documentation Fee: 1TRAVDOC $42.00
Strong,Motion Fee: $0.00 Select an Administrative Iteemm�
Bldp:Stds Commission Fee: $0.00
SUBTOTALS: $105.00 $0.00 TOTAL FEE: t0�"00
Revised: 03/01/2011
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN 35613019 . 00
DATE ISSUED. . . . . . . : 03/03/2011
RECEIPT # . . . . . . . . . BS000012817
REFERENCE ID # . . . : 11030018
SITE ADDRESS 10823 WILKINSON AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER CAROLINA & DEITER MUELLER
ADDRESS . . . . . . . . . . : 10823 WILKINSON AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : TRENCHFREE.COM
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
---------- ------------- ---------- ---------- ---------- ---------- ----
1BCBSC VALUATION 2, 160 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BPWSVCS WATER SERVICE 1 . 00 21 . 00 0 . 00 21 . 00 0 . 00
1BSEISMICR VALUATION 2, 160 . 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 106 . 50 0 . 00 106 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 106 . 50 152
---------------
TOTAL RECEIPT 106 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------ ---------------------------- -------- --------------------------
106 SEWER & WATER 301 ROUGH PLUMBING
507 FINAL PLUMBING
CITY OF
CITY OF CUPERTINO
GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
l c� l .vim Ck 3. l
Building Address:
f 0 A LC� �� o
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
If Residential is house an Eichler? Yes ❑ No ❑ If yes, needs planning approval.
Oer's Name: Phone #:
Contractor- `� - Phone:C GAO— �(.9�
Fax:
Contractor License #:
Cupertino Business License #:
Contact: Phone: .J-(, -3Z(p ,
Fax/e-mail:
Residential ] Commercial WN-,
Job .-
Job Description: 0�� 1'`nC� C Y-t U ,
C9 6 �d( �Q�SLf
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Building Permit Info:
Bldg ❑ Elect ❑ Plumb M Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A, ❑ II/III/V-A ❑ IVIII B, IV-HT, V-B ❑
aluation 1 CO— Square Footage:
Project Size: Counter,2 Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 12/06/10