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09080140CITY OF CUPERTI BUILDING ADDRESS: 10377 BRET AVE `WNER'S NAME: CHRISTINE A PRYOR vVVNER'S PHONE: 4083639693 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. #— Contractor�dun e I hereby affirm thavisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. NO BUILDING PERMIT CONTRACTOR: RCV PLUMBING & PERMIT NO: 09080140 SEWER 4809 RUE LYON CT DATE ISSUED: 08/17/2009 SAN JOSE, CA 95136 PHONE NO: (408) 363-9693 I hereby affirm under penalty of perjury one of the following two declarations 1 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 which this permit is issued. 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 relatin ; 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, 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 th ertino Municipal Code, Section -natur Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for one (f the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensatio: t, 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 which this permit is issued. 1 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 become subject to the Worker's Compensation provisions of the Labor Code, I mu it forthwith comply with such provisions or this permit shall be deemed revoked. 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 relatir g to building construction, and hereby authorize representatives of this city to enter n the above mentioned property for inspection purposes. (We) agree to save .,,emnify 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 pen -nit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. ISignature Date F I BUILDING PERMIT INFO: BLDG ELECT PLUMB rv/ i _. MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: REPLACE WATER MAIN Sq. Ft Floor Area: I Valuation: $1500 APN Number: 37510024 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM L T CALLED INSPECTION. Issued by: RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain com ith the Cupertino Munici de, Chapter 9.12 and the Health & Saf t Code, Secti s ' ,g255 Owner or authorized agen : Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Licensed Professional 5�,. a ' .,i CITY OF ''UPEkTINO JOB Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department PERMIT # [OWNER'S NAME: PHONE # GENERAL CONTRACTOR I am not using any subcontractors: t - ' Si,;nature Date PlaacP rherk 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 Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile o- Owner/ Contractor 4ignature Date Js,l CITY OF CUPERTINO CITY OF 1Z.UPERTINO REPIPE/SEWE]R/MAIN SERVICE PERMIT APPLICATION FORM �gb�bl`�0 APN # � t7 2-7 . �U Date: I� Building Address:: b Owner's Name: o hone #: 1PCSEWER Contractor: �-' 9-3 Phone -363-9U9 _ Fax #: Contact: Phone\�� P 1CPRP Fax #: Contractor License #: Cupertino Business License #: Job Description: Residential Commercial ❑ Valuation: Project Size: Express Standard Large ] Major Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial bu_lding sewer/sanitary : ewer P 11CPSS 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1 PGASCOM Commercial Gz s Piping System 1-4 Outlets P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICOM Seismic Comm -,rcial P Revised 01/07/09 CITY OF C UPERTINO REPIPE/SEWERWUIN SERVICE CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type 1BCBSC Cal Bldg Standard;; Commission Fee B ALL PERMIT TYPES 1 113SEISMICR Seismic Residentiz.1 P 1PRSEWER Residential building sewer/sanitary sewer P 1R -PSS 1PRREPIPE Residential re -pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Di3p0sal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1 PGASRES Residential Gas Pi ?ing System 1-4 Outlets P 1 BPGAS Gas Piping System. 5+ Outlets P 1PPERMITFEE Plumbing Permit F ee Issuance P 1PLMBLNCK Plumbing Plan Ch:ck P 1 PLMBINSP Other Plumbing/gE.s Insp. P 1 TRAVDOC Travel & Documentation Fee B 1 BUSLIC Business License B