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10100174 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21088 GREENLEAF DR CON TRACTOR: PERMIT NO: 10100174 OWNER'S NAME: ROBERT&DENISE GARLOW 0447 DATE ISSUED: 10/25/2010 NER'S PHONE: 4082576885 j P PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONr— I` BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class63 (.e Lic.# � Q�y MECH RESIDENTIAL COMMERCIAL Contractor / Date�4�f s ' L I hereb affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:COPPER REPIPE FROM HOUSE SHUT OFF THROUGHOUT (commencing with Section 7000)of Division 3 of the Business&Professions HOU:;E ONE 3ATHROOM&KITCHEN 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. Sq.F t Floor Area: Valuation:$3500 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:32628002.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 1,80 DAYS FROM LAST CALLED INSPECTION. 9.18. Sign atur Dat 5 Issued by ��-�'��.---- Date: Li OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, instar led without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspe-tion. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to Sign:.ture of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I hai a read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safes y Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's main tain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or art •ized agent: forthwith comply with such provisions or this permit shall be deemed revoked. _ Date./-2 � APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I her:by affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for w hich this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name nnify and keep harmless the City of Cupertino against liabilities,judgments, ,,and expenses which may accrue against said City in consequence of the Lem ler's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. 1 unc erstand my plans shall be used as public records. Signature Date Lice ised Professional CITY OF CU PERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: HATE: REVIEWED BY: APN: BP#: *VALUATION: 1$3,500 q*PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY T tPENTAMATION 1 RPDP USE: SFD or Duplex , �; . PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Area 1PREPPIPE 1 # $42 TOTALS: $42.00 Plumb.PlanHCheck0.0 hrs $0.00 Licecrmit Fee: IPPERMIT h1c r t1r fir.(�r > Other Plumb Insp. �).0 hrs L $42.00 NOTE. Thesefees are based on the prelintinary in ormation available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-05/ LL 7%1;10) FEE QTY/FEE MISC ITEMS nStt'T'l PC'1 cc, T--1 'A PME Plan Check: $0.00 Pcl-11r1,1 FCC-, :Styppi. ITTsp f , PME Unit Fee: $42.00 PME Permit Fee: $42.00 ,1cr�trsftc;ctl l�e�'f'{rt1 I c<r: Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VD0C $42.00 Strong?Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg;Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.50 $0.00 TOTAL FEE: $127.50 Revised: 10/17/2010 CITY OF CUF ERTINO 5 ITEMS OF 5 PERMIT REICEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Iot: APN . . . . . . . . : 32628( 02 . 00 DATE ISSUED. . . . . . . : 10/25/ 2010 RECEIPT #. . . . . . . . . : BS000( 11832 REFERENCE ID # . . . : 101007.74 SITE ADDRESS . . . . . : 21088 GREENLEAF DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ROBER7' & DENISE GARLOW ADDRESS . 21088 GREENLEAF RD CITY/STATE/ZIP . . . : CUPER"INO, CA 95014 RECEIVED FROM . . . . : ONE Dl.Y COMPLETE RE CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----- ----- ---------- ---------- ---------- 1BCBSC VALUATION 3, 500 . 00 1 . 00 0.00 1. 00 0 .00 1BSEISMICR VALUATION 3, 500 . 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 :.27 .50 0. 00 127. 50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- --------------------- CASH 127 .50 --------------- 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 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: ( PERMIT# - C>v -7 OWNER'S NAME: c.,/ PHONE# (c GENERAL CONTRACTOR•. �, > USINESS LICENSE# y - i I �2 ADDRESS: G 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 INS'ECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. l I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 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 � � ► � '-- CITY OF CUPERTINO REPIPE/SEWER/IVIAIN SERVICE CUPEI�TINO PERMIT APPLICrATION FORM APN # ^ f� Date: n n Buildin Address: v\' w er's Name: Phone#: _ Contractor: P one#: �,/09 (-),/1'4 ;/Z/-1,- Fax #: Contact: t, Phone#:Ijlo eL(- Fax #: Contractor License#: Cupertino Business License#: _ Job Description: 9 f r-ts Ve—g \ f-p-- 0 f 4 u' kv'--ks , 00-0- qaf /\ r-0or,, a l'0 Residential Co=ercial ❑ Valuation: Projec Size: Express LJ Standar 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 ICPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Pining System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission_. B ALL PERMIT Fee TYPES 1 BSEISMICOM Seismic Commercia P Revised 01/07/09