10080048 CITY OF CUPERTINO BUILDING PERMIT
[LDING ADDRESS: 10688 HALE PL CONTRACTOR:CUPERTINO PLUMBING PERMIT NO: 10080048
/NER'S NAME: RAY CRUMP
1300 DELL AVE STE C DATE ISSUED:08/05/2010
N
CAMPBELL,CA 95008
ER'S PHONE: 4087490321 PHONE NO:(408)253-0618
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
Lic.11 2— eY �0S MECH r RESIDENTIAL r COMMERCIAL r
ense Class /�
ntractor ( �F'�-r✓ Ply Date Q l"
--� —� JOB DESCRIPTION:COPPER REPIPE&WATER MAIN
ereby affirm that I am licensed under the provisions of Chapter 9
mmencing with Section 7000)of Division 3 of the Business&Professions
de and that my license is in full force and effect.
Hereby affirm under penalty of perjury one of the following two declarations:
ave and will maintain a certificate of consent to self-insure for Worker's
ompensation,as provided for by Section 3700 of the Labor Code,for the Valuation:$4000
rformance of the work for which this permit is issued. Sq.Ft Floo-Area:
lave and will maintain Worker's Compensation Insurance,as provided for by
ction 3700 of the Labor Code,for the performance of the work for which this APN Numl ger:32640013.10688 Occupancy Type:
:rmit is issued.
APPLICANT CERTIFICATION
,ertify that I have read this application and state that the above information is
)rrect.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ion the above mentioned property for inspection purposes. (We)agree to save ROM LAST CALLED INSPECTION.
idemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 D
)sts,and expenses which may accrue against said City in consequence of the
ranting of this permit. Additionally,the applicant understands and will comply Date:
4h all non-point source regulations er the Cupertino Municipal Code,Section Issued b3
ignature / Date_v
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed v ithout first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection
:he following two reasons: Date:
:,as owner of the property,or my employees with wages as their sole compensation, Signature�f Applicant:
gill do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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:
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety C de,with
25532(x)should I Municipal Code,Chapter
to a orhandleha hazardous
&
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
Section 3700 of the Labor Code,for the performance of the work for which this maintair compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
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 er t r su Date: �—y�fe
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
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender s Address
upon the above mentioned property for inspection purposes.(We)agree to save
ir'--rmify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
gi.ating of this permit.Additionally,the applicant understands and will comply I under,tand my plans shall be used as public records.
with all non-point source regulat; upertino Municipal Code,Section
9.18. Licensr d Professional
Signature %"_. Date
771
CITY OF CUPFRTINO
`' REPIPE/SEWEF►/M�.IN SERVICE
CUPS OF
PERMIT APPLICA'CION FORM
Date:
APN #
Building Address: /
L Phone#:
Ow er's Name:
�� CJ2�
Contr t Phone#: Z 5' -- 0618
44 i v ��c,ti �i Fax #:
Contact:
�'` Phone#: 30 5' 3 y
4 t Fax#:
Contractor License#: 4 2 7 ��
cupertino Business License#:
Job Description:
c P� Ad
Residential Commercial ❑
Valuation: f,
Project Size: Express Standard Large M�jor
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the shcet index.
Green Buil ling Points:
Quantity Fee ID Fee Description Fee Permit Type
Grou
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe pi;r 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 CUPE ftTINO
FEE ESTIMATOR-BUIL DING DIVISION
IFADDRESS: DAT E: REVIEWED BY:
APN: BP#: ;VALUATION: $4,000
*PERMIT TYPE: Plumbing Permit PLAN CHEC K TYPE: Alteration/Addition / Repair
PRIMARY /t!;r ;i APPLICATION 1 RPRP
USE:
SFD or Duplex �. „ ��� i l;l,, TYPE
a a
O C
3:
APPLIANCE/EQUIP TYPE CAPACITY FEE ID QTY BP FEES
Re-Pipe Interior IPRREPIPE 1 $11
Fixture or Trap 1BPFIXTURE 8 $64
TOTALS: "xI t'.� $75.00
r Plumb.Plan Check 0.0 hrs $0;00 i:! c '•cu.(lre.c k
ll ,I; !'w mil 1: Plumb.Perm t Fee: IPPERMIT t:lc(. Pcv nw, cc
Other Plumb Insp. OA hrs 1 $42.00
NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info,
FEE ITEMS (l-'ee Resolution 09-051 L f• 7j,"09) FEE QTY/FEE MISC ITEMS
Srriru/. PC Fcc
PME Plan Check: $0.00
!'r'vnrir Icc:
Sr;,,,1,i. 117NI) I'I'I
PME Unit Fee: $75.00
PME Permit Fee: $42.00
Work Without Permit? Q Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Sr,;„r11i,,�orr It Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
r ie .+rhk sY �i�,
!' UB1('Q 'AS. $160.00 $0.00 I( ALEE', $160.00
Revised: 7/28/2010
.Indoor Air Quality and Finishes
_ 1 IAQ/Heelth pts y=yes
2.Use Low VOC,Water-Based Wood Finishes 21AQ/Heelth pts y--yes 0
3IAQ/Heelth 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/Heelth pts y=yes 0
6.Use Exterior Grade Plywood.for Interior Uses 1 IAQ/Ha lth pts y--yes 0
41AQ/He,,Jth pts y=yes 0
S.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes D
10.Install Whole House Vacuum System 3 IAQ/He31th pts y--yes 0
N.Fiooring
1.Select FSC Certified Wood Flooring_ - 6 Res011rcEo pts y=yes 0 = —
2.1be4 RBSOuroo pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resourct: pts yeses 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQIHeelth pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resourc(: pts y--yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resourco pts y=yes 0
1 ! 1
Total Points Available: 1 1401 57
Total Points Project R 0 0 0
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Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR/ SUBCO-vTRACTOR LIST
JOB ADDRESS: 16 �'a v P1, PERMIT# U
OWNER'S NAME: i.. n� PHONE# 6/ ` G 3 2-
GENERAL CONTRACTOR: BUSINESS LICENSE# b L U
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses working in the cit3 to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCO-N4VA tS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. `f- 10
I am not using any subcontractors: Date
Signature
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
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date