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10030108 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22485 RANCHO VENTURA ST CONTRACTOR:AQUA FLOW PLUMBING PERMIT NO: 10030108 OWNER'S NAME: CONNIE&EDWARD CHANG 565 N 6TH ST DATE ISSUED:03/18/2010 JER'S PHONE: 4082555358 SAN JOSE,CA 95112 PHONE NO:(408)265-9504 ❑ LICENSED CONTRACTOR'S DECLARATIONr— ELECT BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class '77 Lie.# Z } MECH r- RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed un r the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER PIPES FM METER TO ALL PLUMBING (commencing with Section 7000)of Division 3 of the Business&Professions FIXTURES W/COPPER PIPE 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 Sq.Ft Floor Area: Valuation:$3000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35701079.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of thi it. Additionall th applicant understands and will comply with all non-'PTP-e.s urce reg o e he Cupertino Municipal Code,Section 9.18. Issued b� ----- Date: Signature Date 0 CI OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: 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 and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Ownrtruth(ril rt become subject to the Worker's Compensation provisions of the Labor Code,I must ? 111111 _Dater / forthwith comply with such provisions or this permit shall be deemed revoked. CON TRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address nnify and keep harmless the City of Cupertino against liabilities,judgments, ` s,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this. ermit.Additionall, tile applicant understands and will comply with all nonioin source ulati r the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature4 A4 Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35701079 . 00 DATE ISSUED. . . . . . . : 03/18/2010 RECEIPT # . . . . . . . . . BS000009974 REFERENCE ID # . . . : 10030108 SITE ADDRESS 22485 RANCHO VENTURA ST SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER CONNIE & EDWARD CHANG ADDRESS 22485 RANCHO VENTURA ST CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2735 RECEIVED FROM AQUA FLOW PLUMBING CONTRACTOR GREGG, DAVID LIC # 21162 COMPANY AQUA FLOW PLUMBING ADDRESS 565 N 6TH ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE (408) 265-9504 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ---------- ------ 1BCBSC VALUATION 3, 000 . 00 1. 00 0 . 00 1 . 00 0. 00 1BPWATER UNIT 1 .00 42 . 00 0 . 00 42 . 00 0 . 00 1BSEISMICR VALUATION 3, 000 . 00 0 .50 0 .00 0 . 50 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 138 .50 0 .00 138 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------------- CHECK 138 .50 #3769 --------------- TOTAL RECEIPT 138 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ----- 301 ROUGH PLUMBING 507 FINAL PLUMBING CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CITY OF CUPEkTINO PERMIT APPLICATION FORM APN# Date: L— 17 Building Address: Owner's Name Phone#,- Contractor: -J Phone#: Fax#: Contact: Phoned,CtU� C- 4P t I/--' Fax#: Contractor License#: Cupertino Business License#: Job Description: kAAA C-G c Residential Commercial E] Valuation: � Az— Project Size: Express E] Standard LJ Large LJ 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 IPCSEWER Commercial building P 1CPSS sewer/sanitary sewer IBPREPIPE Commercial re-pipe per fixture P 1CPRP IPGASC6M— Commercial Gas Piping System P 1-4 Outlets I BCBSC — Cal Bldg Standards Commission B ALL PERMIT Fee TYPES I BSEISMFC—OM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO - REPIPE/SEWER/MAIN SERVICE CUPEI�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group f 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES / 1 BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer / 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1 PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1 TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B Building Department City Of Cupertino [13 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: 2Z+-j S r-cl PERMIT# �� OWNER'S NAME: a Mo i e- E_dloarjN PHONE# G 3 S� 3 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: S Cirt7 �6 ITY/ZIPCODE: s' JAS C �S *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCU A V INSPECTI N(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SU CON A O S AVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. L( C') I am not using any subcontractors: Signature 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 ;) J 004 Roofing Septic Tank Sheet Metal Sheet Rock Tile O -� 17h -6 Owner/Contractor Si `a ure Date