10120059I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 19759 LA MAR DR
OWNER'S NAME: RICHARD Ll
jWNER'S PHONE: 4086216448
❑ LICENSED CONTRACTOR'S DECLARATION
License Class C' —3(0-
3(0 -c. # 3 lq (.{may
Contractor P to Z
I hereby affirm that I am licens d under the provisions of Aapte 9
(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.
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 w ch t is
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 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
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 thi?iiurc
.dditionally, the applicant understands and will comply
with all non-pregulations per the Cupertino Municipal Code, Section
9.18.
Signature Date f2-/(f7//O
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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
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.
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
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.
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 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
lemnify and keep harmless the City of Cupertino against liabilities, judgments,
fists, 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
9.18.
Date
CONTRACTOR: MR. RESCUE PLUMBING PERMIT NO: 10120059
& ROOTER
4231 BUSINESS CENTER DR STE 12 DATE ISSUED: 12/10/2010
FREMONT, CA 94538 1 PHONE NO: (877) 417-3728
JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL
REPLACE SEWER MAIN LINE Lk
Sq. Ft Floor Area:
APN Num
Valuation: $4250
Occupancy Type:
PERM1rEXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
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. I 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 I
will maintain compliance with the unicipal Code, Chapter 9.12 and
the Health & Safety Code, Sectio s 2 75, 3, and 25534.
Owner or authorized agent: Date: 12J.
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
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: -i ,&M&Y- 0Vj IWO PERMIT # 012
OWNER'S NAME: �[:,h�, �,l PHONE # 1- -17- qjj - 372
GENERAL CONTRACTOR: �r. :A4, klAqn6 BUSINESS LICENSE # l (04
ADDRESS:473 ' it 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: �� ` 1z)
Signature Date
Please check applicable subcontractors and complete the following information:
/ Contractor Signature Date
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
►', (2,1 Gt{,L cA^^ 1,1
Roofing
Septic Tank
Sheet Metal
Sheet Rock
FTile
/ Contractor Signature Date
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36910024.00
DATE ISSUED.......: 12/10/2010
RECEIPT #.........: BS000012201
REFERENCE ID # ...: 10120059
SITE ADDRESS .....: 19759 LA MAR DR
SUBDIVISION ......
CITY .............: CUPERTINO
IMPACT AREA ......
OPERATOR: SylviaM
COPY # : 1
OWNER ............: RICHARD LI
ADDRESS ..........: 19759 LA MAR DR
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-3308
RECEIVED FROM ....: RESCUE RESPONSE
CONTRACTOR .......: MIAN AHMED LIC # 31330
COMPANY ..........: MR. RESCUE PLUMBING & ROOTER
ADDRESS ..........: 4231 BUSINESS CENTER DR STE 12
CITY/STATE/ZIP ...: FREMONT, CA 94538
TELEPHONE ........: (877) 417-3728
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
----------
1BCBSC
-------------
VALUATION
----------
4,250.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1BSEISMICR
VALUATION
4,250.00
0.50
0.00
0.50
0.00
1BUSLIC
FLAT RATE
1.00
115.00
0.00
115.00
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
----------
221.50
----------
0.00
----------
221.50
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT
AMOUNT
---------------
221.50
---------------
221.50
VOICE ID DESCRIPTION
-------- ----------------------------
106 SEWER & WATER
301 ROUGH PLUMBING
507 FINAL PLUMBING
REFERENCE NUMBER
--------------------
visa
VOICE ID DESCRIPTION
-------- ----------------------------
202 UNDERFLOOR PLUMBING
400 SEWER/LATERAL
CITY OF CUPERTINO
IIIY"' /7.11 lP1FF. FCTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 19759 lamar dr.
DATE: 12/10/2010
REVIEWED BY: bobs.
UNITS
APN:
BP#:
*VALUATION: 1$4,250
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
USE:
F` f3'.
;l'_t�t>t; .E1l7_ e;
PENTAMATION 1 RPSS
PERMIT TYPE:
WORK
I'it /`
SCOPE
j)I/(win jcc
snio. L%i\1) J -"'c
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Sewer, Sanitary
1 PRSEWER
o. i_ -r t i� i "'v'
1
#
$21
I'it /`
j)I/(win jcc
snio. L%i\1) J -"'c
PME Unit Fee:
$21.00
PME Permit Fee:
$42.00
C on'gl`flt`ttot3 c{..
T-
r
Work Without Permit? 0 Yes (F) No
I
TOTALS:
Travel Documentation Fee: ITRA VDOC
$21.00
Strong Motion Fee: IBSEISMICR
A7/ITO. Tl.l...ond „.:tio nroli"ibinn, infnrmatian availahle and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 E(. Zi 1110)
FEE
Plumb. Plan Check 0.0 1 hrs $0.00
,icc t/on Chc<;,
P/ol" Choc: iUCC_
Plumb. Permit Fee: 1PPERMIT
Other Plumb Insp.0.0 hrs $42.00
o. i_ -r t i� i "'v'
PME Plan Check:
$0.00
A7/ITO. Tl.l...ond „.:tio nroli"ibinn, infnrmatian availahle and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 E(. Zi 1110)
FEE
QTY/FEE
MISC ITEMS
P/ol" Choc: iUCC_
PME Plan Check:
$0.00
I'it /`
j)I/(win jcc
snio. L%i\1) J -"'c
PME Unit Fee:
$21.00
PME Permit Fee:
$42.00
C on'gl`flt`ttot3 c{..
r
Work Without Permit? 0 Yes (F) No
$0.00
1'tf7Ft llit?i r, i'i.'C':i.
Travel Documentation Fee: ITRA VDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$106.50
$0.00J TOTAL FEE:
1 $106.50
Revised: 12/07/2010
CITY OF CUPERTINO
SIM
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
/65/2 6b 5"1
APN #�/ U Ua /
Date:
Building Address:kgJSLJ LQurYVCA,f t>r C�4ex vlb CA Q510`4
Owner's Name: � �C�� L �
Phone #:
Contractor:' y� ,.�,,�
Phone #:
Fax #:
Contact: , �
Phone # u L)3 q y 0.5.5 Z -3
Fax #:
Contractor License #: cT3 j 444P
Cupertino Business License #: r
Job Description: ��h� I �i �1- �— �Wy,( jY� (,� t ►'�
In
Residential Commercial ❑
Valuation: t qr, �� n
Project Size: Express ❑ Standar 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 building
sewer/sanitary sewer
P
1CPSS
1BPREPIPE
Commercial re -pipe per fixture
P
1CPRP
1PGASCOM
Commercial Gas Piping System
1-4 Outlets
P
1BCBSC
Cal Bldg Standards Commission
Fee
B
ALL PERMIT
TYPES
1 BSEISMICOM
Seismic Commercial
P
Revised 01/07/09