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10100037I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 20875 VALLEY GREEN DR C VR'S NAME: WOODMONT PROPERTIES OWNER'S PHONE: 6505923960 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # tl�- 2 t) 2 dS Contractor _�b2 rIJVD Date /�� d I hereby affirm that I am licensed under the provisions of Chapter 9 (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. 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. 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 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, 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 9.18. —_ I.. Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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. 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 to building construction, and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes. (We) agree to save .mify and keep harmless the City of Cupertino against liabilities, judgments, 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 9.18. Signature Date CON TRACTOR: SPENCER CONSTRUCTION PERMIT NO: 10100037 INC PO BOX 1220 DATE ISSUED: 10/07/2010 DAN VILLE, CA 94526 PHONE NO: (925) 984-2581 BUIi DING PERMIT INFO: BLDG F ELECT F PLUMB f— MECH r RESIDENTIAL F COMMERCIAL JOB DESCRIPTION: REPAIR WATER LINE CUT DURING SIDEWALK REPAIR Sq. I t Floor Area: Valuation: $1000 APN Number: 32609064.00 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issu !d by; Date: le) RE -ROOFS: All r>ofs shall be inspected prior to any roofing material being installed. If a roof is insta led without first obtaining an inspection, I agree to remove all new materials for insp< ction. Sign iture of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I ha, le read the hazardous materials requirements under Chapter 6.95 of the Cali ornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain com mliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air cont aminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Hea th & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: nAte: CONSTRUCTION LENDING AGENCY I her eby affirm that there is a construction lending agency for the performance of work's for m ihich this permit is issued (Sec. 3097, Civ C.) Len ler's Name Len ler's ARCHITECT'S DECLARATION I un lerstand my plans shall be used as public records. Lic(nsed Professional 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609064.00 DATE ISSUED.......: 10/07/2010 RECEIPT #.........: BS000(111679 REFERENCE ID # ...: 10100037 SITE ADDRESS ..... SUBDIVISION ...... CITY ............. IMPACT AREA ...... 20875 VALLEY GREEN DR CUPER"INO OWNER ............: WOODM()NT PROPERTIES ADDRESS ..........: 1050 RALSTON AVE CITY/STATE/ZIP ...: CUPER-INO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM ....: SPENC(>N CONSTRUCTIO CONTRACTOR .......: STEVE STAHL LIC # 32035 COMPANY ..........: SPENCER CONSTRUCTION INC ADDRESS ..........: PO BO:: 1220 CITY/STATE/ZIP ...: DANVILLE, CA 94526 TELEPHONE ........: (925) 984-2581 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 1,000.00 ----------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BPWSVCS WATER SERVICE 1.00 21.00 0.00 21.00 0.00 1BSEISMICR VALUATION 1,000.00 0.50 0.00 0.50 0.00 1PPERMITFE 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 ----------- :_06.50 ---------- 0.00 ---------- 106.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 106.50 --------------- 106.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 507 FINAL PLUMBING REFERENCE NUMBER --------------------- #6686 VOICE ID DESCRIPTION -------- ---------------------------- 301 ROUGH PLUMBING CITY OF CU PERTINO FEE ESTIMATOR — BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 20875 Valley Green Drive DATE: 10/04/2010 REVIEWED BY: Larry S UNITS APN: BP#: *VALUATION: $1,000 PERMIT TYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration / Addition / Repair PRIMARY USE: Multi -Family Dwelling.1 f'r.i- {�> ,��,� , PENTAMATION 1RPWS PERMIT TYPE: WORK replace existing damaged water service line at rreter SCOPE ,fi t! pp 1. 111'p APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES rr 1, c' - Water Service 1 BPWSVCS ollIr,r 11" rp 1 # $21 Pc>rmit Fcc,. ,fi t! pp 1. 111'p PME Unit Fee: $21.00 PME Permit Fee: $42.00 Coosirliction Tax F �iaId.Sltt'%fl /7c1'tC'lti 1'E'c': Work Without Permit? 0 Yes E) No $0.00 TOTALS: —1 A Travel Documentation Fee: ITRA VDOC $21.00 Strong Motion Fee: ,.T,f'bTc. 'M A-4 ,. tho nrofiminary iniarmatian availchio and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution 09-051 Etf- 7%7/101 -t "JI PIWi '�E� � , Plumb. Plan Check 0.0 hrs $0.00 MISC ITEMS FFplumb. R:rmit Fee: IPPERMIT rr 1, c' - t "bo AkJL Other Plumb Insp. ).0 hrs $42.00 ollIr,r 11" rp PME Plan Check: $0.00 ,.T,f'bTc. 'M A-4 ,. tho nrofiminary iniarmatian availchio and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution 09-051 Etf- 7%7/101 FEE QTY/FEE MISC ITEMS I/on C hcc 4 Fcc : slipp/. PC Fcc F71 PME Plan Check: $0.00 Pc>rmit Fcc,. ,fi t! pp 1. 111'p PME Unit Fee: $21.00 PME Permit Fee: $42.00 Coosirliction Tax F �iaId.Sltt'%fl /7c1'tC'lti 1'E'c': Work Without Permit? 0 Yes E) No $0.00 Iluyartirr,�r 1.-c�c,,: . —1 A Travel Documentation Fee: ITRA VDOC $42.00L Strong Motion Fee: $0.50 Select an Administrative Item 7 Bldy Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $106.50 $0.00 TOTAL FEE: $106.50 Revised: 9/29/2010 -- �' a -M - CITY OF CUPEkT]NO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM I --1 v ,� ` -1 APN # - 2 to 09 b ' Date: Seo- 2�1 2 01 Building Address: Permit Type 2 0q;q 5 a 11 e Ce m e n b r� Commercial building sewer/sanitary sewf;r P Owner's Name: Phone #: j 59 3 9 Wo(-> 1rnnnA-- MCLKYA0r'.Mf:f P 1CPRP Phone #: C1 -2-S - Ll -00`1 - 2 55' Contractor: Fax #: r'I25 - Ul5�`ti - o 2�3 Contact: Phone #: U 25 - 25s'► �n(c�n C �rLS\YLLOnon Fax #: 6)2- 25t� Contractor License #: '06 2 C 2-0� Cupertino Business License #: -2--, 2 3 `� Job Description:i909 e' .�c t �' 1 i t� C .A- - (1 VYi fi r Residential Cc mmercial ❑ Valuation: I f Project Size: Express Standard Large Major Green Building: Please complete relevant portion of i:he 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 Group Permit Type 1PCSEWER Commercial building sewer/sanitary sewf;r P 1CPSS 1BPREPIPE Commercial re -pips per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System 1-4 Outlets P 1BCBSC Cal Bldg Standards Commission, Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09