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11010059 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10862 WILKINSON AVE CONTRACTOR:JD PLUMBING PERMIT NO: 11010059 OWNER'S NAME: LEE FRIES 270 UMBARGER RD STE 66 DATE ISSUED:01/10/2011 O"""ER'S PHONE: 4082097202 SAN JOSE,CA 95111 1 PHONE NO:(408)646-3266 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r– PLUMB r License Class _Lie.# C((� 2– _ MECH r r RESIDENTIAL COMMERCIAL r Contractor -J Date I hereby affl'rm that I am licensed ander the provisions of Chapter 9 JOB DESCRIPTION: SEWER LINE REPLACEMENT(TRENCH FREE METHOD) (commencing with Section 7000)of Division 3 of the Business&Professions 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. Sq.Ft Floor Area: a $3 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 whic tIP permit is issued. Y APN N :3 ig 1.%R33. % Occupancy Type: APPLICANT CERTIFICATION in 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 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 with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. Signature – »,_--- Date V (% 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: I,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) I,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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 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 OwqPV-QF Compensation laws of California. If,after making this certificate of exemption,I –--- -- Date: +C 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 and expenses which may accrue against said City in consequence of the -mg of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date Building Department City Of Cupertino La 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: C7 ) AJC) PERMIT# OWNER'S NAME: ( PHONE# 40;,2 ZO cl Z G GENERAL CONTRACTOR: �- ( , �,0— BUSINESS LICENSE# ADDRESS: 2 70 lir--�'L,r rCC-L C C --'C75 ( I ( CITY/ZIPCODE: 5 *Our municipal code requires A 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: 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 ner/Contractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 10862 wilkinson ave. DATE: 01/10/2011 REVIEWED BY: bobs. APN: IBP#: *VALUATION: $3,200 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY [PENTAMATION 1 RPSS USE: SFD or Duplex RMIT TYPE: WORK replace 40ft of sewer line add propertV line clean out. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $21 Seader—B ing 1 PRSEWER TOTALS: $427 .00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT t:tc r' ,rr�ir t Ot'rr r tifrl1.IrrtOther Plumb Insp. 0.0 hrs $42.00 C': �" f ic, Inst.l�e: NOTE: These fees are based on the preliminary in ormation available and are onlv an estimate. Contact the Dept for addn'l info. FFEEITEMIS ( ee Resohrtion 09-051 Elf.' 7,/1.%101 FEE QTY/FEE MISC ITEMS f� �c:,: , tpp . Fee PME Plan Check: $0.00 Per 1nit Fee: SuPp1, Insp Fee PME Unit Fee: $42.00 PME Permit Fee: $42.00 C,`t rt. tt trc tion Tax lcazrslicctl l c vicr v Fee: Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRAVDOC $42.00 ` Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item gids Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.50 $0.00 TOTAL FEE: $ .50 00, Revised: 2/07/2010 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35613033 . 00 DATE ISSUED. . . . . . . : 01/10/2011 RECEIPT #. . . . . . . . . BS000012440 REFERENCE ID # . . . : 11010059 SITE ADDRESS 10862 WILKINSON AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA OWNER LEE FRIES ADDRESS . . . . . . . . . . : 10862 WILKINSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM JUAN L DIAZ 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 3, 200 . 00 1 . 00 0 . 00 1. 00 0 .00 1BSEISMICR VALUATION 3, 200 . 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 106 .50 0.00 106 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ---------- CREDIT CARD 106 .50 VISA --------------- TOTAL RECEIPT 106 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING M CITY OF CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN# Date: J !2 Building Address: , Z .� I - Owner's Name: Phone #: LQ E -4 C;< 0 ct `7 -0 Z Contractor: jj Phone#: 6 4 6 3 Z C Fax#: Contact: Phone #: L- J �, ^ 'Z__ Fax/e-mail: Contractor License#: 63 -Z— Cupertino ZCu ertino Business License#: Job Description: ( Y ^C 1-e mac, 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 1 BPREPIPE Commercial re-pipe per fixture P 1 CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERNUT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 12/06/10