09090004 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21601 COLUMBUS AVE CONTRACTOR:PREMIER PLUMBING AND PERMIT NO:09090004
REPIPE INC
O""`ER'S NAME: WILLIAMSON JOAN 1725 ROGERS AVE STE C DATE ISSUED:09/01/2009
O,_iER'S PHONE: 4082555360 SAN JOSE,CA 95112 PHONE NO:(408)903-8184
LICENSED CONTRACTOR'S DECLARATION h
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� Q � BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# % ! r— r
MECH RESIDENTIAL COMMERCIAL
Contractor Date - - �.
1 here affirm that i am licensed under the provisions of Chapter 9 JOB DESCRIPTION:COPPER RE-PIPE FROM WATER WE-A+E Off
(commencing with Section 7000)of Division 3 of the Business&Professions THROUGH
Code and that my license is in full force and effect. ENTIRE HOUSE
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:$8000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35618030.00 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
9.18• Issued �� Date:
y•
i
S;--mature Date 19-311r4 L-1-61- - -
❑ 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
declarations: HAZARDOUS MATERIALS DISCLOSURE
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
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 or auth a t:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
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
V he above mentioned property for inspection purposes.(We)agree to save Lender's Address
I reify 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 permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35618030 . 00
DATE ISSUED. . . . . . . : 09/01/2009
RECEIPT #. . . . . . . . . BS000008576
REFERENCE ID # • . . : 09090004
SITE ADDRESS . . . . . : 21601 COLUMBUS AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER WILLIAMSON JOAN
ADDRESS . . . . . . . . . . : 21601 COLUMBUS AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JOSE MENDEZ
CONTRACTOR . . . . . . . : JOSE MENDEZ LIC # 30877
COMPANY . . . . . . . . . . : PREMIER PLUMBING AND REPIPE IN
ADDRESS . . . . . . . . . . : 1725 ROGERS AVE STE C
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 903-8184
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 8, 000. 00 1.00 0.00 1. 00 0 . 00
1BPWATER UNIT 1. 00 42 .00 0. 00 42 . 00 0 .00
1BPWSVCS WATER SERVICE 1 . 00 21 . 00 0 . 00 21. 00 0 .00
1BSEISMICR VALUATION 8, 000. 00 0 .80 0 . 00 0. 80 0 .00
1PPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 .80 0 . 00 106 . 80 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106 .80 MC
---------------
TOTAL RECEIPT 106 .80
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 301 ROUGH PLUMBING
507 FINAL PLUMBING
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CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
'-SU-1
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
3 6
Building Address:
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wner's Name: Phone#:
ontractor: / Phone#:,y` R
Fax#: z.,lC- -
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Contact: Phone#:
Fax#:
Contractor License#:
Cupertino Business License#:
Job Description: C 901/je-r
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
IPCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P ICPRP
1 PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
TYPES
Fee
1 BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
`f REPIPE/SEWER/MAIN SERVICE
CUPEkTiNO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
I 1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1 PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
IPRREPIPE 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
1PGASRES 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
1 PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
'Building Points Categories that must be
shown and referenced on the Project
Plans See below
tl
-
B. Site 9. Install H.E. Irrigation, (details/spec)"` L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 points
F. Plumbing1. nsulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal.Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Energy Star Refrigerator, (Note/Spec. A-3 1 point
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS1 40 points
Plan Review Process Work Book Page-12-Revised 3/25/08
Community Development
10300 Torre Avenue
w a ;: Cupertino CA 95014
Telephone(408)777-3228
xCIT1(OF Fax(408)777-3333
'UPEkTINO
Buildin De artment
JOB ADD ESS: PERMIT #
O R'S AME: (^J ` h„ v1 PHONE
GENERAL CONTRACTOR: � I FAX #
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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date