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09090182 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19041 BARNHART AVE CONTRACTOR:RAYNE PLUMBING AND PERMIT NO:09090182 SEWER SERVICE OWNER'S NAME: RENEE HENDERSON 517 MADERA AVE DATE ISSUED:09/25/2009 t .BIER'S PHONE: 4084101355 SAN JOSE,CA 95112 PHONE NO:(408)283-0600 ❑ LICENSED CONTRACTOR'S DECLARATIONr— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# r r MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:(POTENTIAL)REPLACE SEWER LINE(PROPERTY (commencing with Section 7000)of Division 3 of the Business&Professions SIDE)AND Code and that my license is in full force and effect. PU IN CLEANOUT 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:$4500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:37509035.00 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 this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section C 9.18. Issued4yc SiQnatur' Date ff OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 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. 1,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 contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Coge,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 534. 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 01 ner ora thorized ent: become subject to the Worker's Compensation provisions of the Labor Code,l must ate: 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 U, `he above mentioned property for inspection purposes.(We)agree to save Lender's Address L tify 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 permi itionally,the applicant understands arti�will comply ARCHITECT'S DECLARATION with all non- source re er the Cupertmi cipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# _ CD Date: . Building Add C(-) � �0 wner'sName: Phone#: R�atmD�f�S�l� X35 Contractor: Phone#: Fax #: Contact: Phone#: Fax #: Contractor License#: '7 9a l Cupertino Business License#: Job Description: . .• (4-0- ���C� Z V\2. C� ��a� ��liv-+ Residential Commercial ❑ Valuation:<$ , 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 building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial Gas Piping System P _ 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE OF CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR 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 1PCESS 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 1PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P r 1TRAVDOC Travel & Documentation Fee B 1 1BUSLIC Business License B CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 37509035 . 00 DATE ISSUED. . . . . . . : 09/25/2009 RECEIPT #. . . . . . . . . BS000008762 REFERENCE ID # . . . : 09090182 SITE ADDRESS . . . . . : 19041 BARNHART AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : RENEE HENDERSON ADDRESS . . . . . . . . . . : 19041 BARNHART AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : RENEE HENDERSON CONTRACTOR . . . . . . . : IONIS, STEVE LIC # 20784 COMPANY . . . . . . . . . . : RAYNE PLUMBING AND SEWER SERVI ADDRESS . . . . . . . . . . : 517 MADERA AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE . . . . . . . . : (408) 283-0600 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 500 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 4, 500 . 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 ----------------- --------------- -------------------- CREDIT CARD 106 .50 VISA --------------- 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 M.Indoor Air Qua illy and finishes 1•Use LDWWVOC Paird 1 IAQ/Health pts y--yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes. 0 3.Use Lowft VOC Adhesives 3 IAQ/Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y=yes 0 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 7 Seat all wedPtr�eboar�l.orMDF 41AQ/Health pts y=yes D 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes kild 1 i N.Flooring 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes D 5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0 1 i 1 Total Points Available: 1 701 1301 57 Total Points Project Received: 0 0 0 2 07 G:data/prog/greenbuildi idelines/remodelers/greenpointsfinal2.12.04protected.xls a* SUNk { � OR September 25, 2009 City of Cupertino Building Department 10300 Torre Avenue Cupertino, CA 95014-3255 Subject: Sanitary Sewer Work Performed at 19041 Barnhart Avenue,APN # 375-09-035, Cupertino, California To Whom It May Concern: Please be advised that the residential unit as referenced above will not have any adverse impact on the City of Sunnyvale's sanitary sewer system. Please call me if you have any questions at (408)730-7616. Ve ruly yours, Eric Gonzales, P.E. Civil Engineer cc: Property Owner Community Development 10300 Torre Avenue '. Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ,;UPE�TIN0 Building Department JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE # GENERAL CONTRACTOR: rev-" FAX # �.v--- I am not using any subcontractors: Z`> ©� Signa a 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date