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10020084 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22415 PALM AVE CONTRACTOR:TATS INC DBA MR PERMIT NO: 10020084 ROOTER PLUMBING 'NER'S NAME: LIGGETT CHARLES F AND KATHLEEN 44777 S GRIMMER BLVD STE C DATE ISSUED:02/16/2010 OWNER'S PHONE: 4084469190 FREMONT,CA 94538 PHONE NO:(408)271-2822 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r— License Class Lic.#;� -7�p MECH RESIDENTIAL COMMERCIAL Contractor Date 1��"�(D "l�� I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE APPRX 35'OF 4"WASTE LINE FM POPTY LINE (commencing with Section 7000)of Division 3 of the Business&Professions TO BLDG,INCLUDE 2 CLEANOUTS 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 Ar Valuation:$5500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Numbers 350302 0 Occupancy Type: APPLICANT CERTIFICATION 1 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 DAY OM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations p he Cupertino Municipal Code,Section 9.18. I // r) Issued by: l CJ Date: -nature Date ! �✓ ❑ 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) 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 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. 1 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 permit is issued. 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 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 Owne _ agent: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: �1� t V forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION 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 the above mentioned property for inspection purposes.(We)agree to save Lender's Address unify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additional ,the applicant understands and will comply with all non-point. vurcVegulaprbhs per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. _ -- � ,�� Licensed Professional Signature Date i CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35703029. 00 DATE ISSUED. . . . . . . : 02/16/2010 RECEIPT #. . . . . . . . . : BS000009753 REFERENCE ID # . . . : 10020084 SITE ADDRESS . . . . . : 22415 PALM AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LI3GETT CHARLES F AND KATHLEEN ADDRESS . . . . . . . . . . : 22415 PALM AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2711 RECEIVED FROM . . . . : FRANCISCO ORELLANA CONTRACTOR . . . . . . . : TATS INC LIC # 23496 COMPANY . . . . . . . . . . : TATS INC DBA MR ROOTER PLUMBIN ADDRESS . . . . . . . . . . : 44777 S GRIMMER BLVD STE C CITY/STATE/ZIP . . . : FREMONT, CA 94538 TELEPHONE . . . . . . . . : (408) 271-2822 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 5, 500 . 00 1 . 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 5, 500 . 00 0 . 60 0 . 00 0 .60 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 .60 0 . 00 106 .60 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 6 . 60 CREDIT CARD 100 . 00 MC --------------- TOTAL RECEIPT 106 . 60 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING C- CITY OF CUPERTINO REPIPE/SEWERIMAIN SERVICE CITY OF CUPEkTINO PERMIT APPLICATION FORM APN # � Date: 7, c4, Building Address: ql,r Alt, Owner's Name: Yhone#: 1. 17 I Contractor: Phone 1� 3 Fax #: Contact: Phone 9 14 g 1, 1 r,c, Fax#: Contractor License Cupertino Business License#: Job Description: F- Residential F71, Commercial ❑ Valuation: oo. 00 Project Size: Express E] 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 IPCSEWER Commercial building P 11CPSS sewer/sanitary sewer IBPREPIPE Commercial re-pipe per fixture P ICPRP IPGASCOM Commercial G,.s Piping System P 1-4 Outlets IBCBSC Cal Bldg Stand irds Commission B ALL PERMIT Fee TYPES IBSEISMICOM Seismic Comm.-rcial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWEFUMAIN SERVICE Uff Of CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1 BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1 IBSEISMICR Seismic Residential P 1PRSEWER Residential buildi:ig P 1RPSS sewer/sanitary seder 1PRREPIPE Residential re-pip.;per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1 PPRSEWG Private Sewage D:sposal System P 1RPWS 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1 BPGAS Gas Piping Systerr. 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Chock P 1 PLMBINSP Other Plumbing/gz s Insp. P 1 TRAVDOC Travel & Documer:tation Fee B 1 BUSLIC Business License B Community Development 10300 Torre Avenue { Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 XPEkTINO Building Department JOB ADDRESS: PERMIT # o �q OWNER' PHONE # -=777' GENERAL CONTRACTOR: R FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI14ESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date