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09110063 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22084 CLEARWOOD CT CONTRACTOR:FRED SABOUR PERMIT NO:09110063 ONVNER'S NAME: FRED SABOUR 22084 CLEARWOOD CT DATE ISSUED: 11/12/2009 ✓NER'S PHONE: 4086743645 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# �J MECH RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL 10'EXPOSED GAS LINE TO NEW (commencing with Section 7000)of Division 3 of the Business&Professions DRYER. 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. Sq.Ft Floor Area: Valuation:$50 I have and will maintain Worker's Compensation hisurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:32618032.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify 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 Issued Date• /12''B with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: ';gnature Date 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 inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533 a 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:le-4- Datc: permit is issued. I 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 Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 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 -)n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION .emnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date1 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32618032 . 00 DATE ISSUED. . . . . . . : 11/12/2009 RECEIPT #. . . . . . . . . : BS000009173 REFERENCE ID # . . . : 09110063 SITE ADDRESS . . . . . : 22084 CLEARWOOD CT SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER FRED SABOUR ADDRESS . . . . . . . . . . : 22084 CLEARWOOD CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : FREDRICK SABOUR CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY FRED SABOUR ADDRESS 22084 CLEARWOOD CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 50 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 50 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PGASRES OUTLETS 1. 00 63 . 00 0 . 00 63 . 00 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 159 . 50 0 . 00 159 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 159.50 VISA --------------- TOTAL RECEIPT 159 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: s A. All the work authorized by this permit B. _ A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owner's Signature: _ -- Date: Job Address: l� j��' i9 - Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. CITY OF CUPERTINO s REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM 0 9//4M6-3 APN# d(� le-03c� Date: Building AddressApz,, r/ Owner's Name: �" GU Phone#: li6 Z, �d Contractor: Phone#: Fax #: Contact: Phone#: Fax #: Contractor License#: Cupertino Business License#: Job Description: 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 11CPSS 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 'RV CITY OF CUPERTINO A ;. REPIPE/S , oF EWER/MAIN SERVICE CUPEkTINO FEE SCHEDULE Quantity Fee IDFee Description Fee Permit Type Group 1 BCBSC Cal Bldg Standards Commission B ALL PERMIT ` Fee TYPES 1BSEISMICR Seismic Residential p 1PRSEWER Residential building P 1RPSS- sewer/sanitary sewer 1 PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool p 1 BPWATER Install/alter Water Pipe p 1 BPFIX TURE 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 1PLMBLNCK Plumbing Plan Check p 1PLMBINSP Other Plumbing/gas Insp, p j1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B r