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10110177 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10571 WHITNEY WAY CONTRACTOR:GREENFIELD PLUMBING PERMIT NO: 10110177 O R'S NAME: PAUL HUANG 3513 MADRID DR DATE ISSUED: 11/29/2010 OWNER'S PHONE: 4089218980 SAN JOSE,CA 95132 PHONE NO:(408)921-8980 41 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB License Class Lic.# `Y Z �Z MECH RESIDENTIAL COMMERCIAL Contractor DateTz - Zpr C:�, I hereby affirm th t I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPIPE NO FIXTURE CHANGEOUTS (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: Valuation:$2000 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. _7T APN Number:36938015.00 Occupancy Type: 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 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;//' 2_101 9.18. S ire Date /0 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the p 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 Owner or authorized agent: Compensation laws of California. If,after making this certificate of exemption,I _ � c� '';AQ/%dk,_Date: Z Z d l 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 tf 'ding construction,and hereby authorize representatives of this city to enter Lender's Address L_ ne 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 ARCHITECT'S DECLARATION granting 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 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36938015. 00 DATE ISSUED. . . . . . . : 11/29/2010 RECEIPT #. . . . . . . . . : BS000012102 REFERENCE ID # . . . : 10110177 SITE ADDRESS 10571 WHITNEY WAY SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PAUL HUANG ADDRESS . . . . . . . . . . : 10571 WHITNEY WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : TOM TRAN CONTRACTOR . . . . . . . : TRAN, TOM LIC # 20711 COMPANY . . . . . . . . . . : GREENFIELD PLUMBING ADDRESS . . . . . . . . . . : 3513 MADRID DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95132 TELEPHONE . . . . . . . . : (408) 921-8980 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 2, 000. 00 1 .00 0 .00 1. 00 0 . 00 1BSEISMICR VALUATION 2, 000. 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 1TRAVDOC FLAT RATE 1. 00 42 . 00 0. 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 127 .50 0 .00 127. 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 127.50 VISA --------------- TOTAL RECEIPT 127 .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 CUPEi�TINO PERMIT APPLICATION FORM APN# 0 Date: Building Ad ress: i t,J Owner's Name: ,� Phone#: a Contractor: Phone#: i E-1 L4 kt40 _ Fax #: Contact: Phone#: Fax #: Contractor License#: � 3 Z Cupertino Business License#: Job Description: ` YT--- Residential Commercial ❑ Valuation: © 0 Project We: Express Standard ❑ Large 0 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