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10120069 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10355 COLBY AVE CONTRACTOR:DEMPSTER PLUMBING PERMIT NO: 10120069 OWNER'S NAME: BLEND IRMA M TRUSTEE 1639 POMONA AVE DATE ISSUED: 12/13/2010 OWNER'S PHONE: 4087288649 SAN JOSE,CA 95110 PHONE NO:(408)295-3911 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ G RE-PIPE IN COPPER FROM THE METER TO ALL FIXTURES, License Class c�J Lic.# O [ S© / REPLACE 2 SHOWER VALVES. Contractor Date 3 To I hereby affirm that I am licensed under the provisions 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. I hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: Valuation:$5000 1. 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 APN Number:31629023.00 Occupancy Type: performance of the work for which this permit is issued. 2. 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 whi h t 7 permit is issued. T EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued - Date: G— 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 RE-ROOFS: all non-point source regu Ron er the Cupertino Municipal Code,Section 9.18. All roofs shall be inspected prior to any roofing material being installed.If a roof is Signature �' Date l2��3/� 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: t. 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 HAZARDOUS MATERIALS DISCLOSURE sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air 1. I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will . Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 2. I have and will maintain Worker's Compensation Insurance,as provided for by Or or a ' t: wn Section 3700 of the Labor Code,for the performance of the work for which this Date: permit is issued. 3. I certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.) Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. 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 Licensed Professional 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 the Cupertino Municipal Code,Section 9.18. Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION PISDDRESS: 10355 colby ave. DATE: 12/13/2010 REVIEWED BY: bobs. PN: BP#: G "VALUATION: $5,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair PRIMARY PENTAMATION 1 RPDP USE: SFD or Duplex b PERMIT TYPE: WORK re i e two shower valves SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Area 1 PREPPIPE 1 # $42 Fixture or Trap 1BPFIXTURE 2 # $16 TOTALS: $58.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.00 NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 09-051 Fff. %/1,70) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $58.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes (F) No $0.00 Travel Documentation Fee: ITRAVDOC $42.00 i Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bl&Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $143.50 $0.00 TOTAL FEE- $143.50 Revised: 12/07/2010 : .7 CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31629023 .00 DATE ISSUED. . . . . . . : 12/13/2010 RECEIPT #. . . . . . . . . : BS000012214 REFERENCE ID # . . . 10120069 SITE ADDRESS . . . . . : 10355 COLBY AVE SUBDIVISION . . . . . . : CITY CUPERTINO IMPACT AREA . . . . . . OWNER BLEND IRMA M TRUSTEE ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2421 RECEIVED FROM . . . . : WILLIAM 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, 000 .00 1. 00 0 .00 1. 00 0.00 1BPFIXTURE NO OF FIXTURE 2 . 00 16 .00 0 . 00 16 . 00 0. 00 1BSEISMICR VALUATION 5, 000 .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 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 258.50 0 .00 258 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 258.50 VISA --------------- TOTAL RECEIPT 258 .50 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 REPIPE/SEWER/MAIN SERVICE ,a_ no CUPEkTINO PERMIT APPLICATION FORM APN # Date: 31�ry �.9 c� Building Address: 103s-'s— lA v e_ Owner's Name- , Phone#: ZID8 -72-T Contractor: Phone#: 1/09 S--f7 5--S7-7 Fax#: Contact: Phone#: o j�/ / ©' �/" Fax#: Contractor License#: Cupertino Business License#: Job Description: Ke Q ; ;� Cu�►P�r- -f-r-owl- '1/t 1,4 car a 'J ` V res Residential �ff Commercial ❑ Valuation: wl� oc 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 Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP I PGASCOM Commercial Gas Piping System P 1-4 Outlets IBCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES IBSEISMICOM Seismic Commercial P Revised 01/07/09