10070184CITY OF CUPERTIP
BUILDING ADDRESS: 10200 MILLER AVE
OWNER'S NAME: PRODOSSE PROPERTY GROUP
10 BUILDING PERMIT
CONTRACTOR: JD PLUMBING I PERMIT NO: 10070184
270 UMBARGER RD STE 66 I DATE ISSUED: 07/28/2010
NNER'S PHONE: 4085206905 SAN JOSE, CA 95111
❑ LICENSED CONTRACTOR'S DECLARATION
License Class — Lic. # U 16 > Z_
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Contractor " (/� W\Gi Date 0�
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 �D
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 ulations per the Cupertino Municipal Code, Section
9.18.
Signatur -''`Datey-7 /28i(
❑ 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 mus
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
-,non the above mentioned property for inspection purposes. (We) agree to save
:mnify and keep harmless the City of Cupertino against liabilities, judgments,
_.,sts, 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
PHONE NO: (408) 646-3266
JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL
3" WATER MAIN PLACEMENT FOR APARTMENT
COMPLEX
Sq. Ft Floor Area: I Valuation: $11000
APN Number: 37503005.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance 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 contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 23560,35533, and 25534.
Owner or authorized agent �, Date: V Z_
JJ
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CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
liaADDRESS:
CAPACITY
I DATE:
QTY
REVIEWED BY:
BP FEES
l APN:
I BP#:
*VALUATION: j$11,000 --7--j
VPERMIT TYPE: Plumbing Permit
P Ali CHECK TYPE:
Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
APPLICATION
TYPE: lcpws
xW
PME Unit Fee:
cc
PME Permit Fee:
$42.00
U
APPLIANCE / EQUIP TYPE
CAPACITY
FEL ID
QTY
BP FEES
Water Service J
1BPWSVCS
1
PME Plan Check:
$21
PME Unit Fee:
$21.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes No
$0.00
TOTALS:
Travel Documentation Fee: I TRA VDOC
$21.00
L F-1 I
Plumb. Plan CheC1 0.0 hr s $0.00
IPlumb. Permit Fee: IPPERMIT
Other Plumb Insp. 0.0 1 hrs 1 $42.00
F
NOTE: These f -es are based on the reli inarvintor ation a,,ailable and are on1v an estimate. Contact the Dept for addnl info.
FEE ITEMS (]-'(-,e Resolution 09-051 tIA-7,11 09
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$000
PME Unit Fee:
$21.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes No
$0.00
Travel Documentation Fee: I TRA VDOC
$42.00
Select an Administrative Item
Bld,a Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$106.001
$0.00 TOTAL FEE:
$106.001
Revised: 7/27/2010