10020027 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 7515 TIPTOE LN CONTRACTOR:NATIONAL ROOTER PERMIT NO: 10020027
OWNER'S NAME: KALVELAGE B F :911 MONROE ST DATE ISSUED:02/03/2010
ER'S PHONE: 4082532586 MANTA CALARA,CA 95051 PHONE NO:(408)241-0887
❑ LICENSED CONTRACTOR'S DECLARATIONBUr—
ILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r RESIDENTIAL� MMERCIAL
Contractor Date ti
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CITY SEWER CLEAN Ou :<
z
(commencing with Section 7000)of Division 3 of the Business&Professions 5
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 d M1 5
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area fr Valuation:$1550
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. APN Nut6ber:3591 9. + 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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 _ /�j�
with all non-point source regulations per the Cupertino Municipal Code,Section [sued by: '?"' -''�-"-'" Dater!y —y
9.18.
Signature Date
RE-ROOFS:
G 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 I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(See.7044,
Business&Professions Code)
I,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 provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,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 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
p 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 person in any manner so as to become subject to the Worker's Ow erre [efed a ►t:
Compensation laws of California. If,after making this certificate of exemption,I � 4 & Date: "2
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 hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
in,' iify and keep harmless the City of Cupertino against liabilities,judgments,
C' ad expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
gra,iurg 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 regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature RcDate U
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Bl.c: Lot:
APN . . . . . . . . : 35 )28009. 00
DATE ISSUED. . . . . . . : 02 /03/2010
RECEIPT #. . . . . . . . . : BS )00009686
REFERENCE ID # . . . : 10 )20027
SITE ADDRESS . . . . . : 75L5 TIPTOE LN
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CU?ERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : KA:JVELAGE B F
ADDRESS . . . . . . . . . . : 75L5 TIPTOE LN
CITY/STATE/ZIP . . . : CU?ERTINO CA, CA 95014-5836
RECEIVED FROM . . . . : BE:ZNARD F KALVELAGE
CONTRACTOR . . . . . . . : R014ALD J. PEREIRA LIC # 25124
COMPANY . . . . . . . . . . : NATIONAL ROOTER
ADDRESS . . . . . . . . . . : 29L1 MONROE ST
CITY/STATE/ZIP . . . : SA14TA CALARA, CA 95051
TELEPHONE . . . . . . . . : (4 )8) 241-0887
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
1BCBSC VALUATION 1, 550 .00 1. 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 1, 550 . 00 0 . 50 0 . 00 0 .50 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 . 50 0 .00 106 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 106 . 50 #2703
---------------
TOTAL RECEIPT 106 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF C.1UPERTINO
.. REPIPE/SEWEI-VMAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # Date
Building Address:
Owner's Nam Phone#:
Contractor: Phone#:
N11 77®l(/
Q - 6 Fax#:
Contact: Phone#:
7
Fax#:
Contractor License#:
7e� ( --36,Cu
Cupertino Business License#:
Job Description:` L �. � ��--� � Q0
Residential Commercial ❑
Valuatio ��� etc-
Project SiW- Expres Standard Large [] Major LJ
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 building P 1CPSS
sewer/sanitary Newer
1 BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
14 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF C:UPERTINO
y . REPIPE/SEWEBJMAIN SERVICE
CITY f
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Descriptio a Fee Permit Type
Group
P 1BCBSC Cal Bldg Standaks Commission B ALL PERMIT
Fee TYPES
1 BSEISMICR Seismic Residenti it P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sevrer
1PRREPIPE Residential re-pip(,per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1 PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1 BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Ch.-ck P
1 PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1 BUSLIC Business License B
Community Development
10300 Torre Avenue
s= ;
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
XPEkTINO
Building Department
JOB ADDRESS: PERMIT#
fs l ,/
OWNER'S NAME: — PHONE # c'=�3
GENERAL CONTRACTOR: �o FAX #
L �
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