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11020029I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 11163 WILKINSON AVE OWNER'S NAME: MIKE & ELIZABETH SHANNON !ER'S PHONE: 4086747261 ❑ LICENSED CONTRACTOR'S DECLARATION License Class C� 3 610 Lic. # 4;�D 10 � ContractorCXAAT'A"45f 160A1A!J &ate ol 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: 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. 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 this permit. Additionally, the applicant understands and will comply with all non -point source re ulations per the Cupertino Municipal Code, Section 9.18. '% Signature Dateo?_ r —�/ LL OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 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 -nnify 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date CONTRACTOR: GREAT AMERICAN PERMIT NO: 11020029 PLUMBING CO INC P O BOX 26942 DATE ISSUED: 02/07/2011 SAN JOSE, CA 95159 PHONE NO: (408)279-1515 BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB [_ MECH i RESIDENTIAL r- COMMERCIAL JOB DESCRIPTION: INSTALL PROPERTY LINE CLEAN OUT Sq. Ft Floor Area: I Valuation: APN Number: 35617044.00 PERMT -EX- P SIF WDRK IS NOT STARTED WITHIN -480 D)Y& ®F PERMIT ISSUANCE OR 180 DAYS FA LAST CALLED INSPECTION. iccued hv: 6? Date: 2-7-// 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 Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owne or !�� 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 I understand my plans shall be used as public records. Licensed Professional 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35617044.00 DATE ISSUED.......: 02/07/2011 RECEIPT #.........: BS000012663 REFERENCE ID # ...: 11020029 SITE ADDRESS ..... SUBDIVISION ...... CITY ............. IMPACT AREA ...... 11163 WILKINSON AVE CUPERTINO OPERATOR: patg COPY # : 1 OWNER MIKE & ELIZABETH SHANNON ADDRESS ..........: 11163 WILKINSON AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: THE GREAT AMERICAN CONTRACTOR .......: CORPORATION LIC # 18061 COMPANY ..........: GREAT AMERICAN PLUMBING CO INC ADDRESS ..........: P O BOX 26942 CITY/STATE/ZIP ...: SAN JOSE, CA 95159 TELEPHONE ........: (408)279-1515 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- ---------- 1BCBSC ------------- VALUATION ---------- 1,950.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 0.00 1BSEISMICR VALUATION 1,950.00 0.50 0.00 0.50 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 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 ---------- 148.50 ---------- 0.00 ---------- 148.50 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 148.50 --------------- 148.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- #117950 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL CITY OF CUPERTINO 9 ..-,_ FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 11163 Wilkinson Ave DATE: 02/07/2011 REVIEWED BY: RDW UNITS APN: BP#: *VALUATION: 1$1,950 - *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: p TPENTAMATION 1 RPSS PERMIT TYPE: WORK Piping, Drainage SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES /J, 1" r tui r' >" Sewer, Sanitary 1 PRSEWER C�rh,�F t.,`s � _ jnsp 1 # $21 Piping, Drainage 1PREPPIPE 1 # $42 PME Unit Fee: $63.00 PME Permit Fee: $42.00 C `rel so-llcfion Kn F71 li:i57 Srrt'£11 R£'vic£ L {' v: Work Without Permit? 0 Yes E) No $0.00 TOTALS: A Travel Documentation Fee: ITRA VDOC $63.00 Stron}7 Motion Fee: 1BSEISMICR NOTE: These tees are based on the Dreliminary information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (Fee Resolution 09-05I Ef . 7,%]!lOZ roc r Plumb. Plan Check 0.0 hrs $0.00 MISC ITEMS Plumb. Permit Fee: IPPERMIT /J, 1" r tui r' >" ship',. PC 1, C" Other Plumb Insp.Lhrs $42.00 C�rh,�F t.,`s � _ jnsp PME Plan Check: $0.00 NOTE: These tees are based on the Dreliminary information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (Fee Resolution 09-05I Ef . 7,%]!lOZ FEE QTY/FEE MISC ITEMS ship',. PC 1, C" PME Plan Check: $0.00 PME Unit Fee: $63.00 PME Permit Fee: $42.00 C `rel so-llcfion Kn F71 li:i57 Srrt'£11 R£'vic£ L {' v: Work Without Permit? 0 Yes E) No $0.00 �%Lint"d7dZ�r I`C'('9': A Travel Documentation Fee: ITRA VDOC $42.00 Stron}7 Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item BldpStds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $148.50 $0.00 TOTAL FEE: $148.50 Revised: 01/15/2011 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: ( jq- pA PERMIT # OWNER'S NAME: PHONE # Z LZ GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: 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 S BCONTRACTORS HAVE OBTAINED BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontrac rs and complete the following information: A CITY OF CUPERTINO Date ner / Contractor Signature 0P- —7 `/ 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile ner / Contractor Signature 0P- —7 `/ Date CITY OF CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE C U P E RT I N O PERMIT APPLICATION FORM APN #�- IC5- Fee ID Date: 22 (1P 7 Building Address: Commercial building sewer/sanitary sewer P 11CPSS AVE - 1BPREPIPE Owner's Name: P Phone #: 1PGASCOM Commercial Gas Piping System 1-4 Outlets Contractor: Phone #: 4� % uw &(404b,,AJ6-- Fax #: -7 -3 Contact: Phone #: Seismic Commercial P Fax/e-mail: Contractor License #: 5z10 (v� Cupertino Business License #: Revised 12/06/10 Job Description: �rs�-�L �iC�9�e�'� G✓��vC �CC�nr � �c� Residential Commercial ❑ Valuation: Project Size: Counter ET 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 building sewer/sanitary sewer P 11CPSS 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 1BSEISMICOM Seismic Commercial P Revised 12/06/10