06060136 CITY OF CUPERTINO �« �^.,+ ^ a a a� "•��"' + `� "^ �`'"`
-BUILDING DIVISION PERNIIT .�cortz.R .c�r Ti1VU,IxMATIN.
BUILDING ADDRESS: GREENFIELD PLUMBING PERMff NO.06060136
1192 CRESTLINE TIP
OWNER'S NAME: PERMIT ISSUE DATE
HUNG 3513 MADRID
NE: SANITARY NO. CONTROL NO.
(408) 921-8980
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
Sap LICENSED CONTRACTORS DECLARATION IO
�n I hereby affirm that I,m licensed under protides,of Chapter 9(commencing
with Section 7000)Of Division 3 ofthc Busirese and Pmfcuwna Code,and my lkmsm is
aji� in fa ITTddoff COPPER REPIPE
$2 License CI Lle.g
°ate OSDECr JUN 27 2006
HIIECI'S DEC
I undonund my plana shall be axed as public ucmdr r��t�++Qyynn��{e{t �we�wwweeeerrravva��eeeeee�ff�ff
BUIL® !
`yG Licensed Proimminal
a OWNER-BUILDER DECLARATION ,
0 S nil
I Main affirm that 11. exempt(ram the demons Co License taw for the
C p o which
reason.(Sedan]1131.5,Business and ere.demi Calc: me em at county
$ which nqusa a pomp reconstruct,alar,improve,h po nnit t ore a sig any awmum $1500
z ire "I kIacamed aalsur 1.the
tbe inions of for sucCmairertre Um esiaw(Chaned ment
(Chapter
�< IMlbeulittnsod pumrantlo de pmvisiov of the Canuxeree,IJcense law(CNpur9 Sq.Ft.Floor Area Valuation
,51 C (cndng with Section 7000)of Division J of the Businessand Profeulan Codc)he
mmonthat he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjec,the applicants in a civil penally of Occupancy Type
act more than five bundmd dollars($500).
0 1,as owner of tial property,or my employees whh wages as Their sole eempevano.
will do the warp and We Income Is natintended mafferad forsale(Sec.7044,Bwineu Required Inspections
and profession Cade:The Communes Liame Law dues sat apply m in awes of q P
propeny who builds or improves Nom n,and who does such wart himsed f m tlnugh his
awnemplaym,provided dem such Impronmena are notlnmmYa arolrend for Wa IL
however,Ne buildintor imphommas is mid within one year ofcompledon,the awnr-
bullder will haw the burden of proving dust he did ms bulb or improve for fourpoae of
sa e.l.
❑1,ss manor of the property.am exclusively"Amusing with licensed cunmioan in
outsmart dee project(See.7064.Busines,and Profesuov Cade:)Ile Comosetter s U.
cove law doe act apply in an owner of Property who builds or Improves thereon,and
who Mo..for each pmjeN with acanuamer(s)teamed Moment to dem Committees
Licenss Law.
❑Iamaemptunder Sege y�y ,BaPCfarthis.
Ower .-�--- /' %/ - Dau . 0
W``pp F SATION DECI.ARATIO
I hembyalum under'.dty of perjury ante of the fallowing declarations:
1 have sad will maintain a CeelOate'of Content to self-Inure for WorkeesCamper.
sedon,we provided for by Section 3700 of the labor Code,for pus performance of dee
west for which This permft is issued. •
❑1 ban and will maintain Wmtees Compenauian Insurance,as required by Seeman
3700.f Ne Labor Cade,far the perfermive of dee wart for which this permit Is laved
My Worker's Compensation Inmratra cattier and Policy number an:
Carrier. Policy No.:
CERTIFICATE OF E%EMFnON FROM WORKERS
COMPENSATION INSURANCE
(Thu section need ambecompleud if du permit Is furan hundred delurs($1001
or less.)
I certify dem in the perfurmana of the work for which this permh is heated.I still not
employ any person in any maaaran as u becomosubject To the Worker'Compemadon
Laws Of Califomu.Date
Applicant
NOTICE TO APPLICANT.If,afar making this Certificates of Exemption,you should
become subject To the Workees Compensation provision,of the Labor Code.you must
OZ forthwith comply with such Provisions!or the permit shall be domed evoked.
ZO CONSTRUCnON LENDING AGENCY
t.v 1 Mreby.hires that Thee is a construction lending agency for the performance of
(Yi > in.work fm which tiffs permit is issued(Sec.3097.Or.C.)
Q Ledoes Nurse
,7 z LeMees Add.
U 0 1 comfy Nu I have read this application and mace that dee above far..due is
D,F cosset.I agree re comply with all city and county on in saes and sum laws Existing To
DU building construction,and hereby amhonre epreaenutives of This city to enter upon the
{Y.1 above-meadaned property for Impaction purpxes.
(We)agree to save•indemnify and Loop harmless do City of Cupertino against
Taj) lietiilites.judgments,Costs atM expenses which may in any my oma agalnl said Chy
U 7 in eavegance of dee grearms of this permit.
•^• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. �-
---J� ��j��t Re-roofs
Signatue of Applican Data 71 pe
USM Tg occum DISCLOSURE '')) Of Roof
Will The a CRantmforum building ac hapten ,1or handle Health
anmaterial
Is dented by the Cupertino Municipal Cade.Chapter 9,13,and the Health and Safety
Cale,Secure 25532(,)7 All roofs shall be inspected prior to any roofing material being installed.
Dyes I�u
40 Will the applicant or fulan Wilding era If a roof is installed without first obtaining an inspection,I agree to remove
g gams sac equipment or MMI which
omit District? ter anumivnts u dcOned by dee cry Ara Air Quality Managcmcm all new materials for inspection.
DlsuktT
❑Yes �fiu
Ihawmwl thematerials25ST5.25533 and 25534.
chapter6.95ofthe Califor- ` n
niaHulNaSefcty Code.Sections35S03,25377 and 23534.1undcnund thatifde bWldin{ C
does MI mm,ently have•.4 dust Ice u my nmpovlld Y re worry the maupmr,or dee
nyuinmcnts which malabemet priormlssu M rnifaau of Occu anus. Signatureo pplica It alt
��.
Owner or anthariynd,{ent D,te All roof coverings to be Class"B"or better
( CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
.m
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36224036.00
DATE ISSUED. . . . . . . : 06/15/2006
RECEIPT #. . . . . . . . . : 34883
REFERENCE ID # . . . : 06060136
SITE ADDRESS . . . . . : 1192 CRESTLINE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : HUNG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5035
RECEIVED FROM . . . . : TOM IRAN
CONTRACTOR . . . . . . . : .TRAN, TOM LIC # 20711 ,. .
COMPANY GREENFIELD PLUMBING .
ADDRESS . . . . . . . . . . : 3513 MADRID DR
CITY/STATE/ZIP . . . : SAN JOSE, CA <95132. . . -
TELEPHONE . . . . . . . . : (408) 921-8980
'PEE ID UNIT. QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BPFIXTURE UNITS . 4 .00 36.00 0.00 36.00 : ..'. 0.00
BPREPIPE NO OF FIXTURE 1.00 9.00 0.00 9.00 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 ..0:00
BPWSVCS WATER SERVICE 1.00 9.00 0.00 9.00 0.00
__________ __________ __________ ----------
TOTAL PERMIT 92.37 0.00 92.37 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -__------______---
OTHER 92.37 VISA
TOTAL RECEIPT 92.37
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
i ! Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
INUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
c D(.DU(,OI S(p
OWNER'S N u ti PHONE # v
GENERAL CONTRACTOR: — FAX # id
I am not using any subcontractors: _ 6< ' 0
ignat a Date
Please check applicable subcontractors-ard 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
CITY OF CUPERTINO
REPIPE/ EWERS/MAIN SERVICE
AN
CUPEkTINO PERMIT APPLICATION FORM
APN# 8 d 2 Date: (0 15 p
Building Address:
Z r-
Owner'sName: Phone#:
Contractor: Phone: License#:
9�
Contact: fPhone: Cupertino Business License#:
* 12 (7
Building Pennit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
0 8
Residential (�" I v -Uminercial ❑
Cost of Project:
• du
Qty. if
Applicable Fee ID Fee Description Fee Group.
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFD{TURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
3)
. G