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09100189 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19801 LA MAR DR CONTRACTOR:CALIFORNIA PLUMBING PERMIT NO:09100189 OWNER'S NAME: JEONGHEE YI 6351 CANDLEWOOD CT DATE ISSUED: 10/28/2009 ER'S PHONE: 4083662588 CUPERTINO,CA 95014 PHONE NO:(408)252-1134 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# (� MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER PIPE REPAIR(EXTERIOR ONLY) (commencing with Section 7000)of Division 3 of the Business&Professions 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 Sq.Ft Floor Area: Valuation:$2300 performance of the work for which this permit is issued. 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 APN Number:36910027.00 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 AYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, l 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: / e 64te: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: 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, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain 1 have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air I have and will maintain Worker's Compensation Insurance,as provided for by 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 Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall Owner o orized agent: p not employ any person in any manner so as to become subject to the Worker's Date: Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affinn that there is a construction lending agency for the performance of work's for which this permit is issued(Sec.3097,Civ C.) APPLICANT CERTIFICATION Lender's Name 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 Lender's Address to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION mify and keep harmless the City of Cupertino against liabilities,judgments, 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 0/3-d2,00 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36910027 . 00 DATE ISSUED. . . . . . . : 10/28/2009 RECEIPT #. . . . . . . . . : BS000009056 REFERENCE ID # . . . : 09100189 SITE ADDRESS . . . . . : 19801 LA MAR DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER JEONGHEE YI ADDRESS . . . . . . . . . . : 19801 LA MAR DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3310 RECEIVED FROM . . . . : JEONGHEE YI CONTRACTOR . . . . . . . : WON KWON LEE LIC # 30674 COMPANY . . . . . . . . . . : CALIFORNIA PLUMBING ADDRESS 6351 CANDLEWOOD CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : (408) 252-1134 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 2, 300. 00 1 . 00 0. 00 1. 00 0 .00 1BPWSVCS WATER SERVICE 1. 00 21 . 00 0. 00 21. 00 0 .00 1BSEISMICR VALUATION 2, 300. 00 0 .50 0. 00 0.50 0 .00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0. 00 42 . 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 MC --------------- TOTAL RECEIPT 106 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING Dq ( O CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# 0 Date: I o 0, q, 0 Building Address: I I I-u Har dr . �L-1 i`nv CA Owner's Name: Phone#: Contractor: Phone#: 46S _ L91 Fax #: Contact: Phone#: Lf opAee YJ r Fax #: 44to _ 11 - 15' Contractor License#: Cupertino Business License#: Job Description: W e Y r re re I c_ry� (,C_X eri c r c4� ) Residential R1 Commercial ❑ Valuation: 2 3 v D Project Size: Express 0 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 1 BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO -af REPIPE/SEWER/MAIN SERVICE CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1 113CBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES j 113SEISMICR 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 1R-PWS 1 PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1 BPWATER 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 j 1PPERMITFEE Plumbing Permit Fee Issuance P f 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P i 1TRAVDOC Travel & Documentation Fee B / 1BUSLIC Business License B