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10050124 CITY OF CUPERTINO BUILDING PERMIT BUIL DRESS: 10370 MIRA VISTA AVE CONTI:ACTOR:ABLE SEPTIC PERMIT NO: 10050124 OWNER'S NAME: MICHAEL P AND KAREN M ZIMMERS P O BOX 24819 DATE ISSUED:05/14/2010 �"'NER'S PHONE: 4089961984 SAN JC SE,CA 95154 PHONE NO:(408)377-9990 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ CI LICE SED CONTRACTOR'S DECLARATION ABATE SEPTIC TANK AND CONNECT TO SEWER. License Class C - Lic.# ' Contractor /t't' 1 L Date O 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. Sq,Ft Floor Area: rc a00I hereby affirm under penalty of perjury one of the following two declarations: t. I have and will maintain a certificate of consent to self-insure for Worker's APN number:35702019.00upancy Type: Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. — ,r N 2. I have and will maintain Worker's Compensation Insurance,as provided for by c" Section 3700 of the Labor Code,for the performance of the work for which this P ERMIT EPItES IF WORK IS NOT STARTED permit is issued. `VITHIN 180'DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION 130 DAYS FROM LAST CALLED INSPECTION. I certify that I have read this applicationand state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating Date: to building construction,and hereby authorize representatives of this city to enter Issue J by: 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 RE-ROOFS: granting of this permit. Additionally,the applicant understands and will comply with All roofs shall be inspected prior to any roofing material being installed.If a roof is all non-point sour a ulat' s per the Cupertino Municipal Code Sect' n 9.18. instal ed without first obtaining an inspection,I agree to remove all new materials for inspe,;tion. Signatur Date Sign2ture of Applicant: Date: '" OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1 uereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: HAZARDOUS MATERIALS DISCLOSURE 1. 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 I hai a read the hazardous materials requirements under Chapter 6.95 of the e,Sections 25505,2553 sale(Sec.7044,Business&Professions Code) California Health&Safety Cod Chapter 9.12 and the and 25534. I will maintain 2. 1,as owner of the property,am exclusively contracting with licensed contractors to Safe ty Code,Sect on 25532(a)should I sto a orehand a hazardous material. & construct the project(Sec.7044,Business&Professions Code). Additionally,should I use equipment or devices which emit hazardous air I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will 1. I have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation,as provided for by Section 3700 of the Labor Code,for the Heath&Safety Code,Sections 25505,25533,and 25534. performance of the work for which this permit is issued. d ,gent p- 2. 1 have and will maintain Worker's Compensation Insurance,as provided for by Date: 4�� Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. CONSTRUCTION LENDING AGENCY 3. 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 I he•eby affirm that there is a construction lending agency for the performance of work's for xhich this permit is issued(Sec.3097,Civ C.) Compensation laws of California. If,after making this certificate of exemption,I Ler der's Name 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 Lei der's Address revoked. ARCHITECT'S DECLARATION APPLICANT CERTIFICATION I understand my plans shall be used as public records. 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 Li(ensed Professional 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, and expenses which may accrue against said City in consequence of the .ng of this permit.Additionally,the applicant understands and will comply with a..non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECHIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lol:. APN . . . . . . . . : 35702019. 00 DATE ISSUED. . . . . . . : 05/14/2110 RECEIPT #. . . . . . . . . : BS000010408 REFERENCE ID # . . . : 10050126 SITE ADDRESS . . . . . : 10370 M: RA VISTA AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER MICHAEL P AND KAREN M ZIMMERS ADDRESS . . . . . . . . . . : 10370 M-RA VISTA RD CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2745 RECEIVED FROM . . . . : ABLE CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407 COMPANY . . . . . . . . . . : ABLE SEPTIC ADDRESS . . . . . . . . . . : P 0 BOX 24819 CITY/STATE/ZIP . . . : SAN JOS];, CA 95154 TELEPHONE . . . . . . . . : (408) 37'1-9990 FEE ID UNIT QUANTITY AMOUNT.' PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -------•--- ---------- ---------- ---------- 1BCBSC VALUATION 7, 500 . 00 '-. 00 0 .00 1. 00 0.00 1BSEISMICR VALUATION 7, 500. 00 0.80 0 .00 0 .80 0.00 1PPERMITFE FLAT RATE 1.00 4:: .00 0.00 42 .00 0.00 1PRSEWER UNITS 1.00 2'-.00 0. 00 21 .00 0 . 00 1TRAVDOC FLAT RATE 1.00 4:'. . 00 0 . 00 42 .00 0. 00 ------ --- ---------- ---------- ---------- TOTAL PERMIT 106. 80 0 .00 106 . 80 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- --------------------- CHECK 106 .80 145'13 --------------- TOTAL RECEIPT 106 . 80 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- - ------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CITY OF CUPERTINO REPIPE/SEWEWWAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN # Date: J _ Cz -01q --�- Building Address: )' vim Owner's Naunge Phone#(4o6) R�(n6— 0-84 Contractor: Phone#:(40) S-n-99&19 Fax#: 0419 Contact: i '� Phone Fax#: *Z-LV'3 Contractor License#: Cupertino Business License0?- #: / Q Job Description: ��IrTi►+u� IL Residential %r-M Commercial ❑ Valuation: l S U ✓-- Project Size: Express 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& the:sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial Buildin; P 1CPSS sewer/sanitary sewe- 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Pilling System P 1-4 Outlets 1BCBSC Cal Bldg Standards '—ommission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C U P E RTI N O Telephone: 408-777-3228 CONTRACTOR /SUBCONTRACTOR LIST Fax: 408-777-3333 JOB ADDRESS: 101-10 1-AMA V IsT� �Y, PERMIT# OWNER'S NAME: r�y� �lW►v�ArS PHONE# a GENERAL CONTRACTOR: r\rx,r- coo-rtc- BUSINESS LICENSE# ADDRESS: jor2r Q qrj O CITY/ZIPCODE: 5 *Our municipal code requires all businesses working in the 2ity 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: ignatu re 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