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12030014C1TY OF CUPE.R'1-INO BUILDING IT10,11T nun.DlNC,ulf)IZFSS: 6060 WILLOW GROVE LN CON I(Acroit:GREA'I-ANIFRICAN pesaB'rNO: 12030014 PLUMBING CO INC OtrNER'S SAM.: SONAI_REGE PO 13OX 269,12 DATE. ISSurl):03/05/2013 OWNrli'spn0ut: 1087778696 SANJOSE.CA 95159 pnONr;NO:(,108)279-1515 ❑ LICENSED CONTRA CI,0It's DECLARATION r r r BUILDING PE.1 . 1IT INFO: full)(: F.I.I:Cr I•LD.MR /' �7 [�I / License ClasS_` ✓ � Lic. 9�_V.[�_b S r r r comaetnrG�e�sC+�c�cs�w_P_c�•,w:.l3al _3_S—r 2 dIKCII RESIDENTIAL COMMERCIAL I hereby affirm Ilial I nm licensed wider the prnrisions of Chapter '/ .IOII DESCRIP I'lON: PROPERTY LINE CLEAN OUT (Com nwncillL will, Section 7000) of Division 3 of the Itusiness S P. ofessiuns Cale and that nn' license is in full force and effect. I hereby of I1 utid Cr penal ('til' perjury one of, IIte fullmvill I; two dCr Ill I nIi11115: I have and will nmintain a certihe:tic of consent Io self-insure for Worker's Compensation, as provided for by Section 3700 ol'Ihe Labor Code, for the Sq. fl Floor Arca: Valuation: 52350 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided Ibr by Section 3700 of the Labor Code, for the performance of the work for which this .permit is issued. AVN Souther: 37538021.00 Occup:ruey'1'ype: JB AppLICANT CR 11FICATION 1 cenih•that l have read this application and stale that the Minae information is PElil\'I IT EXPIRFIS IF\VORK IS NOTSTAIiT D correct. I agree to comply with all city and County ordinances and slave laws relating 180 DA1'$OI'PE121\'ll-II$$lJA\CE OR to to building construction, and hereby authorize representatives of this city to neer upon thcabove mentioned property for inspection purposes. (We)agree to sav 180 DAVS -RO11 LASTCA LLED INSPECTION. indernnify and keep harmless the City of Cuperino against liabilities, judgments, r costs• and expenses which stay accrue against said City in consequence ol'the - granting of this pCollif. Additionally, th1e applicant lnldcrstands laid will crmnph, Issued by: 1C DaI with all non-point source regulations per the Cllpertitio Mn111Clpal Code, Section 9.18. llingm Signal e_ _ _ _ _ Uate 3-s / All roots shall be inspected prior many rooting material being installed. It'll roof is ro installed without first obtaining an inspection. I agree to remove all new materials for inspection. ElOAA'Milt-R1111.UPat DECLARATION Signature of Applicant: Duce: I hereby affirm Thal I am cavo( pi 1'nun the Conit'acinr's Licrnx• bane fur one of Ibr following ani reasons' AIA. ROOF C)VEItINCSTO 1117 CLASS "A" OR Itr: ITER 1, as owner of the property, or 111)' crlplo)Res with %wages as their sole compensation. will do the work, told the structure is not intended or offered for sale (Sec.704.L Business' R Professions Code) I, M owner of the properly. am exclusively contracting with licensed contractors to I6N%A RDOOS dLVI FRIA INS DISCLOSUIt Ii construct the project (Sec.70,14. Business R professions Code). 1 hays read the hazardous mile. ials requirements under Chapter 6.95 of the California Ileallh \ Safely Chic. Sectionn'_5505. 25533. and 25534. 1 will 1 hereby alliin under penally of perjury one of Ibr folk... inn IhrCC maintain compliance with the Cupertino Municipal Code. Chapter 9.1'_ :rod the declarations: I Icalth & Safct' Calc, Section 25532(a) should I store or handle hazatilous I have and will maintain a Certificate of Consent In set -insure for Worker's nuvcrial. Addiliun:dlv, should I use equipment ur devices which cntil hazat'lous Compensation, as provided for b)Section 3700 of the Labor Code, for file air cull l:uni till tib as defined by Ibr Bay Area Air Quality Mana_cment District I performance of the work for which this permit is issued. will nlaimain Compliance with the Cupertino %I unicipal Code. Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the I lealth & Safely Code. Sc tions 25. I . 25533, and 25534. Section 3700 of the Labor Code. Ibr the performance of the work for which this Owner or I. Permit is issued :unhorizrd aLc - - - — - I certify that in the performance of the work for which this permit is issued. 1 shall not employ any person in any planner so as to become subject to the Worker's Compensation laws of California. If. after making this certificate of exemption, I CONS1'RUC'1'I0N LISNUING AGENCY become subject to the Worker's Compensation provisions of the labor Code, I must I hereby afliml that then is it construction lending agency for the pertbmlance of forthwith comply with such provisions or this permit shall be devoted revoked work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name 1% VpIIC\N"1' CEltd'I FI CAT 10N Lender's Address I cenify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and suite laws relating to building construction. and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (tfC) agrtC to save and keep harmless the CITY of Cupertino against liabilities• judgments. ,\ItCI II'1'IiCI"S DECLARATION costs• and expenses which may accrue against said City in consequence of the I understand tip' plans shall be used as public records. graining of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino %lUnicip;l Code. Sectio u Licensed Professional 9.18. Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ......... 37538021.00 DATE ISSUED.......: 03/05/2012 RECEIPT 4.........: BS0000IG182 REFERENCE ID # ...: 12030014 SITE ADDRESS .....: 6060 WILLOW GROVE LN SUBDIVISION ...... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: SylviaM COPY # : 1 METHOD OF PAYMENT --------- CHECK TOTAL RECEIPT AMOUNT --------------- 142.50 --------------- 142.50 REFERENCE NUMBER -------------------- 122150 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------------------------------------------- ---------------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING OWNER ............: SONAL REGE ADDRESS ..........: 6060 WILLOW GROVE LN CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: GREAT AMERICAN PLUM CONTRACTOR .......: CORPORATION LIC # 18061 COMPANY ..........: GREAT AMERICAN PLUMBING CO INC ADDRESS ..........: P O BOX 26942 CITY/STATE/ZIP ...: SAN JOSE, CA 95159 TELEPHONE ........: (408)279-1515 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL -ADMIN --------------------- HOURS 1.00 -------------------- 41.00 0.00 ---------- 41.00 ---------- 0.00 1BCBSC VALUATION 2,350.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 2,350.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 44.00' 0.00 44.00 0.00 1PRREPIPE NO OF FIXTURE 1.00 12.00 0.00 12.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 TOTAL PERMIT 142.50 0.00 142.50 0.00 METHOD OF PAYMENT --------- CHECK TOTAL RECEIPT AMOUNT --------------- 142.50 --------------- 142.50 REFERENCE NUMBER -------------------- 122150 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------------------------------------------- ---------------------------- 301 ROUGH PLUMBING 507 FINAL PLUMBING CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333' buildino(6mloet'no.or0 USIPLUNBING ❑MECHANICAL ❑ELECTRICAL MEP III LSC 12�3Go/ F NLSMtnNEM PAORiCT ADDRESSIL do APN9 `� �S CA I U� OWNER NAME`C PHONE — q EmAm r, REET KESS STADD I Cr, -Y. STATE ZIP �U FAX CONTACT NAME Jct IWC S -IDroE PHONE 7 -1475- E-M/A�D. STADOAE55 ��G N, �V CITY, S'REE7 ( rt� UOS Cj Lti �/ c G FAXIiZ , L O !3 WR 11❑ ONEOWNER-BUILDER // ❑ OWNEAAGE.Nr ymNLUCPOR ❑CO:RAACTORAGEIT ❑ ARCB]FLT ❑EVGLVP.Ea ❑ DEVE!.opm ❑ �A CONP.UCT'OA NAME G/!� (AAJ wbN LICENSE NUMHER�v / IICENS'E TYPE/ ^ \ s 3US IdCp �� COMPANY TAME E-MAIL _ FAX *"7!5 STREET ADDRESS CInr, STA cZ8 �^ �f I P90NE _ ARCRTECWENOINEER NAME LICENSE NUMBElk BOB. LIC p COMPANY NAME' E -MAR FAX STREET AIlORE55 CITY, STATE, ZIP PHONE USE OF 0 SFD or OUPL'Y BUDDING: C¢FLHc cC ❑ MULD-FAMRY PAOTFLT A' WTiOIwND O YEs I PROTECT IN ❑ YEs URBAN INTERFACE AREA NO FLOOD ZONE ❑ No I LS na BLOO AN ❑ YES E cIamt. HOME) ❑ NO OFSCAIFTION OF WOR:< N 1 PVZ0 21- U.-VC rA,,V 0 ut ,- TOTAL VALUATION: U RECEIVED BY: ' By my signature below, I certify w each of the rollowing I are the pmpery owner or authm-iud agent to act. on the property mover's behalf. I have read this application and the information I b e provide is cora tj have 'F Description=Work acrd verify it is azmnate. I agu to conmly with all applicable local ordinarrces and sEate Taws relating 'din c n au[honu represeatadves of Cnpms¢ to rnter ti:e above-iden¢yed pmptry br itLspecdo¢ puloses. - Signature of AppficandAgrn Due: 3 -67-/ � UPPL&YEENTAL MFORiINfATION REQUIRED OFFICE U5E ONLY v c Y U U ❑ OVER-THE-COUNTER ❑ CaRESS ❑ STANDARD 11 LAItCE ❑ MAJOR MEPMucApp_2011.doc revised 06/21/11