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09100227 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20303 CLIFDEN WAY CONTRACTOR:TBD-TO BE PERMIT NO:09100227 DETERMINED OWNER'S NAME: MICHELLE KIM DATE ISSUED: 10/30/2009 dNER'S PHONE: 4086212923 PHONE NO: ❑ LICENSED CONT'RACTOR'S DECLARATION 1f— f— �2/!_ 11 BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class 71G Lic.#�t12�1�1� f— f— F_ MECH RESIDENTIAL COMMERCIAL Contractor��, + �Y1�C1� GDate._ ' Jr�. I hereby affirm that 1 am licensed under th@'provisions of Chapter 9 JOB DESCRIPTION: MAIN SEWER REPLACEMENT WITH CITY (commencing with Section 7000)of Division 3 of the Business&Professions CLEAN OUT Code and that my license is in full force and effect. *SEE NOTES* 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$200 1 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 APN Numbe 36935040.00 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 by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: mature__.— a 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: AL1.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). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penalty-af perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Fade,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 provider'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. nd 2 534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent:. JV Date; I certify that in the performance of the work for which this permit is issued,I shall not employ any person in ary 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 agenex for the performance of forthwith comply pith 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 thai 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 •i the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION n:nify and keep harmless the City of Cupertino against liabilities,judgments, t costs,and expenses which may accrue against said City in consequence of the 1 understand my pians 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 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36935040 . 00 DATE ISSUED. . . . . . . : 10/30/2009 RECEIPT #. . . . . . . . . BS000009091 REFERENCE ID # . . . : 09100227 SITE ADDRESS . . . . . : 20303 CLIFDEN WAY SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MICHELLE KIM ADDRESS . . . . . . . . . . : 20303 CLIFDEN WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : RONALD PENNINGTON 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 200 . 00 1 . 00 0. 00 1. 00 0 . 00 1BSEISMICR VALUATION 200 . 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 CITY OF CUPERTINO Fy REPIPE/SEWER/MAIN SERVICE COF CUPERTINO PERMIT APPLICATION FORM bg 100212-1 APN# _ Date: 10 " 30 A o Building Address:. . (fi" (i Owner's Name: Phone • - ContraPhone#: -736r-- e3l/,� to Lrk t 0 �11i Fax#: -7-300- 6116 Contact: 0 Phone#: (W) 2/q, 62-06 l`�Y1 Fe"'Xn 10 61 Fax #: Contractor License#: `?q2 e?q r Cupertino Business License#: Job Description: Residential � Commercial ❑ Valuation: 42-1006 Project Size: Express Bard ❑ 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 1PGASCOM 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 ti REPIPE/SEWER/MAIN SERVICE CUPEkTINO 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 I sewer/sanitary sewer IPRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1 PPRSEWG 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 IBPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B IBUSLIC Business License B Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 rUPERTINO Building Department JOB ADDRESS: PERMIT # 9�0,-,P;6 Cllfk'n NZ, (�C"Ad- OWNER'S NAME: MI cjjpu PHONE # 6 161 - 2-6 GENERAL CONTRACTOR: FAX # C '. 736 - '/l I am not using any subcontractors: 10- 36 , 07 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