11010122 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10197 DENISON AVE CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 11010122
OWNER'S NAME: PHILIP BOHANNON& EMILY UNDERWOOD 1639 POMONA AVE DATE ISSUED:01/24/2011
I ER'S PHONE: 4085647893 SAN JOSE,CA 95110 PHONE NO:(408)295-3911
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class C Jr Lic•# a O q MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date l` ZY
JOB DESCRIPTION:REPIPE IN COPPER FROM METER TO ALL FIXTURES
I hereby affirm that I am licensed under the provisions of Chapter 9 EXCEPT
(commencing with Section 7000)of Division 3 of the Business&Professions BOTH SHOWERS&KITCHEN SINK
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,eF'Section 3700 of the Labor Code,for the performance of the �b�y s Sq.Ft Floor Area: Valuation:$5650
permit is issued.
APPLICANT CERTIFICA ON APN Number:31628022.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
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
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued bDate: 7�-1
Signature Date /�z
L, OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Date:
Business&Professions Code) Signature of Applicant:
I,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
declarations: HAZARDOUS MATERIALS DISCLOSURE
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
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)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
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I Owne o ed t• l �Z�j/�j
become subject to the Worker's Compensation provisions of the Labor Code,I must Date•C
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
,mnify and keep harmless the City of Cupertino against liabilities,judgments,
;,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Signature
Date Licensed Professional
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C O P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 10 (9-7 o4v L PERMIT# d l 4:�l 2-Z-
OWNER'S NAME: -f I&&-lit-o <t1^6 ry PHONE# 4109-5Z -/ ?37-'7.3
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: L6. 9 t&&^a-14- AvC CITY/ZIPCODE: S �J-
*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 SUBCONT ORS 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
Owner/Contractor Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 31628022 . 00
DATE ISSUED. . . . . . . : 01/24/2011
RECEIPT #. . . . . . . . . BS000012551
REFERENCE ID # 11010122
SITE ADDRESS 10197 DENISON AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PHILIP BOHANNON & EMILY UNDER
ADDRESS . : 10197 DENISON AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2426
RECEIVED FROM . . . . : WILLIAM D DEMPSTER
CONTRACTOR WILLIAM DEMPSTER LIC # 31263
COMPANY . . . . . . . . . . : DEMPSTER PLUMBING
ADDRESS . . . . . . . . . . : 1639 POMONA AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95110
TELEPHONE (408) 295-3911
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ---------- ----------
1BCBSC VALUATION 5, 650 . 00 1 .00 0.00 1. 00 0 . 00
1BSEISMICR VALUATION 5, 650 . 00 0 .57 0 .00 0 .57 0 . 00
1PPERMITFE FLAT RATE 1. 00 42 .00 0 .00 42 . 00 0 .00
1PREPPIPE 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 127 .57 0 .00 127 .57 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -----
CREDIT CARD 127 .57 VISA
---------------
TOTAL RECEIPT 127 .57
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- --
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
506 GAS TEST 507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10197 denison ave. DATE: 01/24/2011 REVIEWED BY: bobs.
APN: BP#: *VALUATION: 1$5,650
q*PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Du lex PENTAMATION 1 RPDP
USE: p PERMIT TYPE:
WORK re i e interior only no fixture change outs.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Area 1PREPPIPE 1 # $42
TOTALS: $42.00
Afech_ Plan Chcc_k Plumb.Plan Check 0.0 hrs $0.00 11u c- P/on
11"Ch. F"-Y" Plumb.Permit Fee: IPPERMIT I-;It c f ert;tit FCC
F-1 I
Oiluer Ak(h.Imp Other Plumb Insp. El hrs $42.00 Cltlacr {;lec_Inst).
tjc(h. Int) FCC' 1'hImb_ Tial;. t�A" f'�'{.Ins1J. 11CO,
NOTE: Thesefees,are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (I ee Res ttion 09-051 Eff. 74/102 FEE QTY/FEE MISC ITEMS
PhIlt C hecl
Sapp/. I'C'1"ecl
PME Plan Check: $0.00
11(,.'i"init f-ec
.Slt1)I)l. Insp I ee
PME Unit Fee: $42.00
PME Permit Fee: $42.00
CVc)ta.slt rat tiott 7-LM'
1c�)t sl'icr.tl Rt'view P'fv:
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Strong Motion Fee: IBSEISMICR $0.57 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $127.57 $0.00 TOTAL FEE: $127.57
Revised: 01/03/2011
t
CITY OF
CITY OF CUPERTINO
1101 012-2--
REPIPE/SEWERJMAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# � C I k r1 Date: I
Building Address:
O 1 97 evA t So to Ae
Owner's N Phone #:
:jam o� �K � 4vi?S&V
Contractor. (�I Phone #: 4o P �q7-rS�`7
0�" S,'�r pl✓r►-b� -7 Fax#: 4or 2453GTi/
Contact: Bal ��„��s-�,r- Phone#: 4,,0y _5--J/ /o py
Fax/e-mail:
Contractor License#: 19VS047
Cupertino Business License#:
Job Description: �,� cep P pe t -�,ro ,� wJ rhe, z� / .:r ✓r& -e cep—
go-f N
Residential ,�� Commercial ❑
Valuation:
Project Size: Counter 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 Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 12/06/10