09100179 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21371 VAI AVE CONTRACTOR:ABLE SEPTIC PERMIT NO:09100179
OWNER'S NAME: JUDY TERREL P O BOX 24819 DATE ISSUED: 10/27/2009
w ER'S PHONE: 4086614228 SAN JOSE,CA 95154 PHONE NO:(408)377-9990
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB
License Class C--'AL_ Lie.# QZZgZ5- MECH f— RESIDENTIAL I— COMMERCIAL
ContractorDate &-1-7`�
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CONNECTING TO EXIST SEWER LATERAL
(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:$4800
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:36205015.00 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 D �-
granting of this permit. Additionally,the applicant understands and will comply Issued Date,
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. VL
�
R a t4
Signature_3�4 Date- -R t`<. F � ;
Nw
- All roofs shall be inspected pri an" ali .. installed.If a roof is
❑ OWNER-BUILDER DECLARATION installed without firs p t 'ung an _ p 'io o remove all new materials for
inspection. �;
fi ,4r
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
a.
the following two reasons: Signature of Applicank..,.;_ Date:
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,
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. I will maintain
I 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 workfor 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 C e,Sections 25505,25533,and 25534.
permit is issued.
1 certify that in the performance of the work for which this permit is issued,I shall Oo o i gent: 2q_o'
not employ any person in any manner so as to become subject to the Worker's GG 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 affirm 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
i, iify and keep harmless the City of Cupertino against liabilities,judgments,
a, ,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
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36205015 . 00
DATE ISSUED. . . . . . . : 10/27/2009
RECEIPT #. . . . . . . . . BS000009045
REFERENCE ID # . . . 09100179
SITE ADDRESS 21371 VAI AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JUDY TERREL
ADDRESS 21371 VAI AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4934
RECEIVED FROM . . . . : ABLE UNDERGROUND CO
CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407
COMPANY ABLE SEPTIC
ADDRESS P 0 BOX 24819
CITY/STATE/ZIP . . . : SAN JOSE, CA 95154
TELEPHONE (408) 377-9990
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 4, 800 . 00 1 .00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 4, 800 . 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
----------------- --------------- --------------------
CHECK 106 .50 #13258
---------------
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
' REPIPE/SEWER/MAIN SERVICE
CIT CUPEi�TINO PERMIT APPLICATION FORM
Coq t o CD l l cl
APN # Date:
CP(
Buil} - -n (res/ Al AR.,
Owner's Name: PW-*
�� T�rt.Ia 1
Contractor: I Phone#:
Contact: one#: 'I"Z.— ��
Fax#:
Contractor License#: 9-
Cupertino
Cu ertino Business License#:
Job Description:
M
Residential �� Commercial ❑
Valuation:
Project Size: Express Standard 91 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
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
Of
CUPERTINO 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
sewer/sanitary sewer
1PRREPIPE Residential re-pipe per fixture P 1R-PRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
113PGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1 PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
M.Indoor Air Quality and Finishes
1-rase LOWN640C Pad. 1 1AQIHealth pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use low/1# 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
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7. I�LLt 41AQ/Health. pts y=yes 0
8.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 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 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 130E-- 57
Total Points Project Received: 01 0 0
G:data/progs/greenbuilcOngguidelines/remodelers/greenpoir 6na12.12Nprotected.xls
Community Development
10300 Torre Avenue
'- Cupertino CA 95014
Telephone(408)777-3228
CITY OF
.;UPE�TINO Fax(408)777-3333
Building Department
JOB
ADDRESS:
`ESSvvi� PERM
OWNER'S NAME:: PHONE # 0
GENERAL CONTRACTOR: IMF FAX # Z- 1369-
I am not using any subcontractors:
SiRgil 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
c
Owner/Contractor Signature Date