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10090220 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1305 S STELLING RD CONTRACTOR:AMERICAN PLUMBING& PERMIT NO: 10090220 DRAIN TER'S NAME: AGROSKIN YURY AND SOPHA 4463 HOLLOW GATE LN DATE ISSUED:09/22/2010 OWNER'S PHONE: 4082056141 SAN JOSE,CA 95127 PHONE NO:(408)205-0506 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB License Class Lic.4 4 S , ` 0 [— r Q MECH RESIDENTIAL COMMERCIAL Contractor��"cA— `C J,��34t Date 0'+ ,a- l r) I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL A CITY CLEAN OUT WITHIN 5 FEET FROM (commencing with Section 7000)of Division 3 of the Business&Professions SIDEWALK 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 r Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: ation:$1200 permit is issued. f �I.x APPLICANT CERTIFICATION APN Number:36626016.00Occupancy Type: 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 °" ti to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERM E IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the W AYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply I FROM LAST CALLED INSPECTION. with all non-point sou a regulations per the Cupertino Municipal Code,Section ; 9.18. Issued by. Date: Z 2 ,cure Date with all non-poin 7 ❑ ER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by 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 Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25W,25533,and 25534. 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 0'" r aut �ie -�a !� forthwith comply with such provisions or this permit shall be deemed revoked. Date: CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION r� I certify that I have read this application and state that the above information is I reby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name the above mentioned property for inspection purposes.(We)agree to save .unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk-: Lot: APN 36E26016 .00 DATE ISSUED. . . . . . . : 09/22/2010 RECEIPT #. . . . . . . . . : BS( 00011535 REFERENCE ID # . . . : 10( 90220 SITE ADDRESS . . . . . : 1305 S STELLING RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER AGROSKIN YURY AND SOPHA ADDRESS . . . . . . . . . . : 1305 S STELLING RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MARIO D FRANCISCO CONTRACTOR MARIO D. FRANCISCO LIC # 27114 COMPANY . . . . . . . . . . : AMERICAN PLUMBING & DRAIN ADDRESS . . . . . . . . . . : 4463 HOLLOW GATE LN CITY/STATE/ZIP . . . : SAP1 JOSE, CA 95127 TELEPHONE . . . . . . . . : (408) 205-0506 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 200. 00 1. 00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 1, 200 . 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 FEE ESTIMATOR-- BUILDING DIVISION ADDRESS: I DATE: REVIEWED BY: APN: I BP#: "VALUATION: 1$1,200 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: 1 PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $21 TOTALS: T $21.00 Plumb.Plan Check 0.0 hrs $0.00 Plur ib. Permit Fee: 1 PPERMIT Other Plumb Insp. 0.0 hrs $42.00 NOTE: Theseees are based on the preliminaryinformation available and are onl an estimate. Contact the De t or addn'!info. FEE ITEMS (Fee Resolution 09-051 E(f. 7/1/10) FEIN; QTY/FEE MISC ITEMS F-1 PME Plan Check: $0.00 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? © Yes (F) No $100 Travel Documentation Fee: ITRA VDOC $42.00 A Strong Motion Fee: $x.500.5 hrs Adm' al Fee Bldg Stds Cormnission Fee: IBCBSC $1.00 $39 IAD SUBTOTALS: $103.50 $39.00 TOTAL FEE: $145.50 Revised: 9/22/2010 Building Department City Of Cupertino Lai 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: C> l Q- —„ -, Vic, PERMIT# �� OWNER'S NAME: PHONE# GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: \-346 JVQ- f}LAi-e 51-e- CITY/ZIPCODE: Q, *Our municipal code requires all businesses working ir, the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTFACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: �� � ��� � ll Si;nature Date Please check applicable subcontract anMompl ete the following information: V 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 0wner/Contractor Signature Date CITY OF CUPERTINO ( `'O c� `�� Z REPIPE/SEWS i SERVICE CUPEkTiNO PERMIT APP]JICATION FORM APN# � % J /f �� / � Date: Building Address. o Owner's Name: �ONA Phone#: Contractor: r 6 Contact: Phone#: Fax #. Contractor License#: Cupertino Business License#: Job Description: Residential Commercial ❑ Valuation: c o�; Project Size: Express'JW 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& :he sheet index. Green Building Points: a Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial bui.ding P 1CPSS sewer/sanitary si:wer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Ga: Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standa-ds Commission, B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09