10100071 CITY OF CUPER TINO BUILDING PERMIT
BUILDING ADDRESS: 10305 CALVERT DR CONTRACTOR:C&C VALLEY PERMIT NO: 10100071
CONSTRUCTION CO, INC
'NER'S NAME: VERONICA JOSEFSBERG 2405 KLEIN RD DATE ISSUED: 10/08/2010
OWNER'S PHONE: 4086876945 SAN JOSE,CA 95148 PHONE NO:(408)238-1244
❑ LICENSED CONTRACTOR'S DECLARATION1—
C, BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# r
MECH RESIDENTIAL COMMERCIAL
Contractor Qom/. (�.(�(f� `,� Date Iw ,- JOB DESCRIPTION:CHANGE EXISTING SEWER LINE MAIN
I hereby affirm that I am licensed under the provisions o Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professior s
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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$3000
I have and will maintain Worker's Compensation Insurance,as provided for b}
Section 3700 of the Labor Code,for the performance of the work for which thi; APN Number:37517019.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws re ating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to en:er
upon the above mentioned property for inspection purposes. (We)agree to sav a 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgmer ts,
costs,and expenses which may accrue against said City in consequence of the Issued e: . eiQ- d,
granting of this permit. Additionally,the applicant understands and will comp y
with all non-point source regulations per the Cupertino Municipal Code,Section -
9.18. F
nature ' DateA6 All roofs shall be inspected primo' any mg 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
Signature of Applicant: Date:
I hereby affrrrh that I am exempt from the Contractor's License Law for ne of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compen!ation,
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 contracto-s 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. I 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 Cu ertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for b:, the Health&Safety Code,Sections 05,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which th,s
Owner or authorized agent: Q Date:/ O
permit is issued.
I certify that in the performance of the work for which this permit is issued,I s gall
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 exemptio i,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, 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
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 re lating
building construction,and hereby authorize representatives of this city to er ter
a 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 comp y
with all non-point source regulations per the Cupertino Municipal Code,Secti m Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATO-11-BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$3,000
;PERMIT TYPE: Plumbing Permit FLAN CHECK TYPE: Alteration /Addition/ Repair
PENTAMATION
PRIMARY ;�; t t 1 RPSS
USE: SFD or Duplex PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Sanitary 1PRSEWER 1 # $21
TOTALS: $21.00
1•t. .1r t".� C'Yc`: Plumb.Plan('heck 0.0 hrs $0.00 f'/�"n(.:a <°;�
Plumb.Permit Fee: IPPERMIT
r. F-1 Other Plumb [ns 0.0 �rs $42.00EIF
C)t:xt ?l�. IrAc> P�
f'ir,r th. 1r,', . 5, , is 1`c't
NOTE: Theseees are based on the preliminaryin ormat ion available and are onlyan estimate. Contact the De t or addn'1 info.
FEE ITEMS (ree Resolution 09-051 7%1"HY FEE QTY/FEE MISC ITEMS
S1/X17/. PC'Fee
PME Plan Check: $0.00
1'c>r Ir"it Fcc°.
rrt? 71. 111sp FFec
PME Unit Fee: $21.00
PME Permit Fee: $42.00
,-Ic,)Ztst/c of 1&,vices /,-cc:
c:
Work Without Permit? 0 Yes E) No d$42.00
C'Icrrtrrirl�r f'�r�'.�:
Travel Documentation Fee: I TRA VDOC i
Strong Motion Fee: $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: :1106.50 $0.00 TOTAL FEE: $106.50
Revised: 9/29/2010
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec : Twp: Rng: Sub: 31k: Lot :
APN . . . . . . . . : 37517019. 00
DATE ISSUED. . . . . . . : LO/08/2010
RECEIPT #. . . . . . • • . : 35000011687
REFERENCE ID # . . . : L0100071
SITE ADDRESS . . . . . : 10305 CALVERT DR
SUBDIVISION . . . . . . .
CITY �UPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JERONICA JOSEFSBERG
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : 2UPERTINO, CA 95014
RECEIVED FROM . . . . : ENRIQUE COUTTOLENC
CONTRACTOR . . . . . . . : JOE COTA LIC # 31448
COMPANY . . . . . . . . . . : 2&C VALLEY CONSTRUCTION CO, IN
ADDRESS . . . . . . . . . . : 2405 KLEIN RD
CITY/STATE/ZIP . . . : 3AN JOSE, CA 95148
TELEPHONE . . . . . . . . : (408) 238-1244
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 3, 000 . 00 1 . 00 0 .00 1 . 00 0 . 00
1BSEISMICR VALUATION 3, 000 .00 0 .50 0 .00 0 . 50 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 .50 0 .00 106 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106 .50 VISA
---------------
TOTAL RECEIPT 106 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF CUPERTINO
:R REPIPE/SE / 010007/
WE SERVICE
CM OF
CUPEkT1NO PERMIT APPLICATION FORM
APN#
`� D 1 g y 00 Date:.
Building Address:
/0301Y Y. (v G� . l .�(�
Owner's Name: Phone#:
i:ontrac r: Phone#:
! ; G-6 C 2;1`:b 14- Fax #: 6? ,Z/l '4 0 - 6
Contact: Phone#:
Fax #:
Contractor License #: ,2
Cupertino Business License #: y�j
Job Description:
l
Residential Commercial ❑
Valuation:
Project Size: /Express Standard L Large [T 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,,ewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-40 utlets
1BCBSC Cal Bldg Standzrds Commission, B ALL PERINIIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09