10110190 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10741 GASCOIGNE DR CONTRACTOR:MASTER PERMIT NO: 10110190
PLUMBING&SEWER INC
OWNER'S NAME: KATHRYN BECKER 144 S WHISMAN DR DATE ISSUED: 11/30/2010
OWNER'S PHONE: 7149060770 MOUNTAIN VIEW,CA 94042 PHONE NO:(408)945-1000
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lic.# !R-1 2,7�1'1 r- r —
MECH RESIDENTIAL COMMERCIAL
Contractor ''�./ Date t I 30
I hereby a rm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: PROPERTY LINE CLEAN OUT
(commencing with Section 7000)of Division 3 of the Business&Professions SEE NOTES
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: ' 1'atio 5500
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 APN Number:3753102 :,. Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION 4
I certify that I have read this application and state that the above info ion is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN,180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the U O
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations
^per the Cupertino Municipal Code,Section
Signature W \ Date l ��` �� 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.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ti ns 25505 5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this I
Owner or authorized agent:
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
' 'ify that I have read this application and state that the above information is
.;t.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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37531021 .00
DATE ISSUED. . . . . . . : 11/30/2010
RECEIPT #. . . . . . . . . : BS000012112
REFERENCE ID # . . . : 10110190
SITE ADDRESS . . . . . : 10741 GASCOIGNE DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KATHRYN BECKER
ADDRESS . . . . . . . . . . : PO BOX 247
CITY/STATE/ZIP . . . : HUNTINGTON BEACH, CA 92648
RECEIVED FROM . . . . : MASTER PLUMBING
CONTRACTOR . . . . . . . : BART ADAMS LIC # 25402
COMPANY . . . . . . . . . . : MASTER PLUMBING & SEWER INC
ADDRESS . . . . . . . . . . : 144 S WHISMAN DR
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94042
TELEPHONE . . . . . . . . : (408) 945-1000
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 500 . 00 1 . 00 0 . 00 1 . 00 0 .00
1BSEISMICR VALUATION 5, 500 . 00 0 .55 0 . 00 0 .55 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 .55 0 . 00 106 .55 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106.55 VISA
---------------
TOTAL RECEIPT 106 .55
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10741 gascoigne dr. DATE: 11/30/2010 REVIEWED BY: bobs.
APN: BP#: *VALUATION: 1$5,500
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex 7 7'111. PENTAMATION 1 RPSS
USE: I,I c ft�h' tr`�:;,��: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $21
TOTALS: $21.00
Plumb.Plan Check 0.0 hrs $0.00 (`a;,:r�?:
Plumb.Permit Fee: IPPERMIT t'
Other Plumb Insp. 0.0 hrs $42.00 ��,,� , ,r,rt;. Li
NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS (Fee Resolution 09-051 Elf. 7%1,I0) FEE QTY/FEE MISC ITEMS
PhIIr Circ':k 1'c"
PME Plan Check: $0.00
Pcrini" F4'c"
St1pp/' 111"p ['Cc
PME Unit Fee: $21.00
PME Permit Fee: $42.00
(.'ollso-t%c°tion Ta
[�r�trstt�rtl Rcri,,tiff
Work Without Permit? 0 Yes E) No $0.00
CCIN
Travel Documentation Fee: ITRA VDOC $42.00 A
Strong;Motion Fee: IBSEISMICR $0.55 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $106.55 $0.00 TOTAL FEE: $106.55
Revised: 11/08/2010
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
0116f q0APN# � ! ^�/ Date: /� 3 p`!b
Building Address:UA5(-0 T.CTN
i0-1yl
Owner's Name: Phone#:
+E.r n 3EGCR- `7 / 906 o')-) O
Contractor: - Phone#: L(0 �{ S I v U O
M �S L V Ml Fax#:
Contact: ��,� Phone#: qoF,
Fax #:
Contractor License#:
Cupertino Business License#:
Job Description: C C- �.✓C-iz- L I fV G
Residential ] Commercial ❑
Valuation:
Project Size: Express Standard 0 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
1 PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09