10110178 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21962 WOODBURY DR CONTRACTOR:ALLSTAR PLUMBING PERMIT NO: 10 110 178
G ;R'S NAME: ARNOLD CROSS 326 PHELAN AVE DATE ISSUED: 11/29/2010
OWNER'S PHONE: 4082570660 SAN JOSE,CA 95122 PHONE NO:(408)230-5569
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class I Z�e Li,# '3CP p MECH r— RESIDENTIAL[— COMMERCIAL
Contractor ft r PLf vMbw.Date I (` ( (C)
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: SEWER LINE REPLACEMENT
(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: Valua 0
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 4, 1,
permit is issued. APN Number:32639020.00 00 ancy Type:
APPLICANT CERTIFICATION
I certify that I have read this ap 'cation and state that the above information is
correct.I agree to comply with city and county ordinances and state laws relating PERMIT E STORK IS NOT STARTED
to buildingconstruction,and h eb authorize representatives of this city to enter r(_..rrn• +
upon the ove mentioned pro erty for inspection purposes. (We)agree to save WITHIN 1 'DA, S OF PERMIT ISSUANCE OR
indemnify and keep harmless he City of Cupertino against liabilities,judgments, 180 DAYS FEZ LAST CALLED INSPECTION.
costs,and expenses which ay accrue against said City in consequence of the
granting of this permit. A itionally,the applicant understands and will comply /
with all non-}foint source egulatiops-per the Cupertino Municipal Code,Section Issued b Date:
9.18.
S e Date`
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:
1,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 Additiona , Id I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this cont, ' ants as de red by the Bay Area Air Quality Management District I will
permit is issued. main in complianc with the Cupertino Municipal Code,Chapter 9.12 and the
P Heal &Safety Co e,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 Own4 or cd4gentr--
Compensation laws of California. If,after making this certificate of exemption,I Dater
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
tr 'ding construction,and hereby authorize representatives of this city to enter Lender's Address
U, ,ie above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
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 . . . . . . . . : 32639020 . 00
DATE ISSUED. . . . . . . : 11/29/2010
RECEIPT #. . . . . . . . . : BS000012104
REFERENCE ID # . . . : 10110178
SITE ADDRESS . . . . . : 21962 WOODBURY DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : ARNOLD CROSS
ADDRESS 21962 WOODBURY DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DAVID GRIJALVA
CONTRACTOR . . . . . . . : DUARTE TADEV LIC # 22189
COMPANY . . . . . . . . . . : ALLSTAR PLUMBING
ADDRESS . . . . . . . . . . : 326 PHELAN AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95122
TELEPHONE . . . . . . . . : (408) 230-5569
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 8, 000 . 00 1 .00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 8, 000. 00 0 .80 0. 00 0 .80 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 .80 0 .00 106 . 80 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106 .80 VISA
---------------
TOTAL RECEIPT 106 .80
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: 21962 woodbury dr. DATE: 11/29/2010 REVIEWED BY:
APN: BP#: *VALUATION: 1$8,000
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY 7-07A1, PENTAMATION 1 RPSS
USE: SFD or Duplex t�'7E)<1 ii,i is PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1 PRSEWER 1 # $21
-T-
TOTALS: $21.00
lfc(h. /'!m(1-icr k Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: IPPERMIT I�tc Pt
F-1 I-- Other Plumb Insp. 0.0 hrs $42.00 !wp
9Ic;t. Ina63 I
NOTE: Thesefees are based on the preliminary into rmation available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 09-051 E('. 7,1110) FEE QTY/FEE MISC ITEMS
Phl)r C/lec h
I f 'A
PME Plan Check: $0.00
supp[ 111sp 1-'C" F
PME Unit Fee: $21.00
PME Permit Fee: $42.00
C misirlrctaon TcLV F
1cousiiccr/Revici
Work Without Permit? 0 Yes No $0.00
I'lcrftrtirr,�7 Fer<',s:
Travel Documentation Fee: ITRAVDOC $42.00
Strong Motion Fee: IBSEISMICR $0.80 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $106.80 $0.00 TOTAL FEE: $106.80
Revised: 11/08/2010
Building Department
City Of Cupertino
LM 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: v,i mad av PERMIT# 0l 7
OWNER'S NAME: PHONE# 0 561-{o
GENERAL CONTRACTOR: S�� w.�' BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses rking in Jhe city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OC UPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL UBCON ACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. ar
Iam not using any subcontractors: 2 Ld
14ignature Date
Please check applicable subcontrac rs and comple �in:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring /Carpeting
Linoleum /Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
/ 0 / /
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # .�
GO
5 9 02-0
Date:
Building Address:
2 t -L :,u u-,• �.
Owner's Name: Phone#: ala
cy-oss 2S -
Contractor: Phone#:
Y Fax #:
Contact: Phone#:
1{0$ -�-01 Fax #:
Contractor License#:
Cupertino Business License#:
Job Description:
L c wuyX .
Residential Commercial ❑
Valuation:
13,6`
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
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1 BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09