10080066 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22606 VOSS AVE COIN TRACTOR:SAN JOSE PLUMBING INC PERMIT NO: 10080066
OWNER'S NAME: J G&CAROL LOUGHLIN 1732 HILLSDALE AVE DATE ISSUED:08/09/2010
4ER'S PHONE: 4083953556 SAN JOSE,CA 95124 PHONE NO:(408)296-1820
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r— PLUMB r
License Class Lic.# / MECH F RESIDENTIAL COMMERCIAL r
Contract r Date
I hereby trm that I am licensed under the provision of Chapter 9 JOI t DESCRIPTION:COPPER REPIPE OF DUPLEX FROM METER
(commencing with Se tion 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 wok for which this permit is issued. Sq. Ft Floor Area: Valuation:$12000
1 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
APPI Number:34229026.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have r this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
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 ection Issi ted by: l 3 Date:
9.18.
Signature Date
_�LRE-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 am exempt from the Contractor's License Law for one of insl>ection.
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 stricture is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,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 p vided for by Section 3700 of the Labor Code,for the coi npliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of thew rk for which this permit is issued. Sa'ety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Ac ditionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this co ataminants as defined by the Bay Area Air Quality Management District I will
mf intain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any persc n in any manner so as to become subject to the Worker's 01 or g nt:
Compensation laws f California. If,after making this certificate of exemption,I _ Date:
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 1 ereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION fo: which this permit is issued(Sec.3097,Civ C.)
I certify that I haver md this application and state that the above information is L<rider's Name
correct.I agree to co nply with all city and county ordinances and state laws relating
to building construct on,and hereby authorize representatives of this city to enter L4 rider's Address
upon the above men coned property for inspection purposes.(We)agree to save
. ,nnify and keep rmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
,and expenses which may accrue against said City in consequence of the
g,anting 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 egulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signatur Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 34229026 .00
DATE ISSUED. . . . . . . : 08/09/2010
RECEIPT #. . . . . . . . . : BS000011132
REFERENCE ID # . . . : 10080066
SITE ADDRESS . . . . . : 22606" VOSS AVE
SUBDIVISION . . . . . .
CITY CUPEPTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : J G b: CAROL LOUGHLIN
ADDRESS 2260( VOSS AVE
CITY/STATE/ZIP . . . : CUPEF.TINO, CA 95014
RECEIVED FROM . . . . : DAVID PLEMONS
CONTRACTOR GARZT., KEVIN N LIC # 14200
COMPANY . . . . . . . . . . : SAN DOSE PLUMBING INC
ADDRESS 1732 HILLSDALE AVE
CITY/STATE/ZIP . . . : SAN DOSE, CA 95124
TELEPHONE (408) 296-1820
FEE ID UNIT QUANTITY AMCUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 12, 000. 00 1 . 00 0.00 1. 00 0 .00
1BPWSVCS WATER SERVICE 1 .00 21 .00 0. 00 21. 00 0 .00
1PPERMITFE FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 .00
1PRREPIPE NO OF FIXTURE 1 .00 11 .00 0. 00 11. 00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0.00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 117. 00 0. 00 117. 00 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 117.00 VISA
---------------
TOTAL RECEIPT 117 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: E ATE: 08/0912010 REVIEWED BY: gs
APN: BP#: 'VALUATION: $0
R�IPERMITYPE:
TYPE: Plumbing Permit PLAN CI[ECK TAlteration /Addition / Repair
PRIMARY 101;21_ APPLICATION 1RPRP
USE: SFD or Duplex I1'1.001v1 A1 L 1, TYPE:
� a
00
3 �
FLR ARF A BP FEES
APPLIANCE/EQUIP TYPE CAPACITY s f QTY
Re-Pipe Interior 1PRREPIPE 1 $11
Water Service 1 BPWSV(,S 1 $21
TOTALS: $32.00
Plumb.Plan Check 0.0 hrs $0.00 1 1'w(I'V
�. Plumb.Permit Fee: I PPERMIT
I T-1 I
Other Plumb Insp. 0.0 1 hrs 1 $42.00 E'h", tr, I"
NOTE: These fees are based on the preliminarrTy in ormation avaij able and are on1v an estimate. Contact the Dept for addn'l info.
F,FEEITEIM* S (Fee Resolution 09-051 F.f. 7/1/09) FEE QTY/FEEMISC ITEMS
Fcc:
lipp . �O"
PME Plan Check: $0.00
Puiwilr Fcc,
Sapp, 172sp Fcc
PME Unit Fee: $32.01)
PME Permit Fee: $42.01)
011 T(IN I _=_
iC��ttsttt`rtt hcl iclt'I.t,e,:
Work Without Permit? 0 Yes C) No $0.0)
Phrt,tz�l�;w
cc""
Travel Documentation Fee: ITRA VDOC $42.00
Select an Administrative Item
S/11,); l fr,� O'j '
F31dp,Stds Commission Fee: $O.0 0
SUBTOTALS: $116.00 $0.00 TOTAL FEE: $116.00
Revised: 8/06/2010
ove
CITY OF U PERTINO r
REPIPE/SEWER/T4AIN SERVICE
CUPEkT1NO PERMIT APPLICATION FORM
APN # Date:
i1 �_ < i
Building Address:
Owner's Name: Phone#:
C I
Contractor: Phone #: /
Fax #:
Contact: Phone#:
Fax #:
Contract6r-License#:
Cupertino Business License#:
Job Description: A/ C_
Residential Commercial ❑
Valuation:
Ql1 L7
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of :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 Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewor
.A.
1BPREPIPE Commercial re-pips;per fixture P 1CPRP
1PGASCOM Commercial Gas P:ping System P
1-4 Outlets
1BCBSC Cal Bldg Standard: Commission,. B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09