09100148 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18901 ARATA WAY CONTRACTOR:TBD-TO BE PERMIT NO:09100148
DETERMINED
( WNER'S NAME: SANTHINE V MENON DATE ISSUED: 10/22/2009
OWNER'S PHONE: 4087321425 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class &� Lic.#
L f MECH RESIDENTIAL COMMERCIAL.
Contractor — Date 9�/ � -
1 hereby affirm that I am licensed der the provisions of Chapter 9 JOB DESCRIPTION: SEWER REPLACEMENT&DRAIN CLEAN &
(commencing with Section 7000)of Division 3 of the Business&Professions CITY CLEAN OUT.
Code and that my license is in full force and effect. MR RESCUE PLUMBING &ROOTER PD FOR BUS LIC.10/22/9
1 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 elk
performance of the work for which this permit is issued. Sq.Ft Floor Area: tion: 000
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 AP b 51 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 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: / zvC
� T
with all non-point source reguI tion the Cupertino Municipal Code,Section
9.18.
c
e� ° `Z2 2cti RE-ROOFS:
nature 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.
11OWNER-BUILDERDECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 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 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I 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 Cuperti al Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections ;15 n 5534.
Section 3700 of the Labor Code,for the performance of the work for which this 1 22 2 C
permit is issued. Owner or authorized agent: Date:
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I 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 _
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
building construction,and hereby authorize representatives of this city to enter
on the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
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 Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37512039 . 00
DATE ISSUED. . . . . . . : 10/22/2009
RECEIPT #. . . . . . . . . : BS000009010
REFERENCE ID # . . . : 09100148
SITE ADDRESS . . . . . : 18901 ARATA WAY
SUBDIVISION . . . . . . :
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : SANTHINE V MENON
ADDRESS . . . . . . . . . . : 18901 ARATA WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : MR RESCUE PLUMBING
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 000 . 00 1 . 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 1, 000 . 00 0 .50 0 . 00 0. 50 0 . 00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 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 220 .50 0 . 00 220 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 220 .50 1282
---------------
TOTAL RECEIPT 220 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPE(�TINO PERMIT APPLICATION FORM
APN # Date:
Building AdGe-ss: 2032Anvk
Ow;'s Name: AV n 6r Phone#:
.%,4 Yam--7 3.Z -4 y 267'
Contractor: f7Q'6 Phone#:
V
M�• ' tt_ („�w�.�, I Fax#: � -Z'ZS'Y
Contact: Phone l� !o�7. -77�q
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Contractor License#: q 3/ Ll u y
Cupertino Business License#:
Job Description: D
A7v-.)
C/,-
Residential [ Commercial ❑
Valuation:
Project Size: Express Standard Large El 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
INPUT Resources Energy IADHealth
Indoor Air uality and Finishes
1.Use 1.ow/No-VOC Paint 1 IAQ/Health pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
S.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 01
! 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B 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 0
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 1 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: 01 01 0
G:data/progs/greenbuildingguidefines/remodelers/greenpointsfinal2.12.04protected.xls
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
.;UPEkTINO
Building Department
JOB ADDRESS: PERMIT rer/ ft L( 010
OWNER'S NAME: PHONE # 73-z 7-6'
GENERAL CONTRACTOR: mG-. l,,.il -4&XAX #
I am not using any subcontractors:
Signa e 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/Con ctor Signature Date