06120107 CITY OF CUPERTINO aam—as�e-W,
BUILDING D IVISION PERMIT ,CON R CTQIZ INFO MATI01V y„
BUILDING ADDRESS: PERMITNO.
OWNER'S NAME: ATE
VARDY SHTEIN 12/20/2006
NE: SANITARY NO. CONTROL NO.
ARCHfIECT/ENGINEER: MP��I� �W'aa alr/I BUILDING PER rr -0
1Y BLDG ELECPLUMB
T PLUMB MECH
0 0 0 0
�O0 LICENSED CON'rRACTOR'S DECLARATION Job Description
:w❑ I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing P
'iW with Sees.70M).(Divitum3ofNCBusinessandProkssiunCode.andmylicenseu INSTALL BACK FLOW DEVICE AT SIDE OF BUILDING
=�y in fan force and effe<s
License Class Lic.9 ._
•t,I Due Comrawr
ARCHITECTS DECLARATION
wU I underwznd my plans shall be used as public mends
y Licensed Professional
5 OWNER-BUILDER DECLARATION
I
21 hereby alines that I am exempt from the Contracmrs License Law for the
:O o following..an.($anon 7W I.S.Business and Pmfessbm Cak:Any city or county
m which requites a permit to construct alms.improve,demolish,or repair any structure
�¢a pnorm is issuance,also mqumm ease applicant forsuch permitm file asigntsmmmem
< Chat he is licensed pursuant m the,provisions of the Connector's Liana Law(Chapter 9 Sq.Ft. Floor Area Valuation
$1250
h51 (ca,he Is(commencing Section andfcD osis n3 the
theContraption.
Profusion Cation of
Wt he u campy an appli and the buns far Ile subjects
thalleged emmpnt to Any violation of
Seton 7031.5 by airy applicant for a permit subjects Ne applicant to a civil penalty ofNumber Occupancy Type
net mom man live hutdmd dollars(35110). 35910060 .)W
❑1,u owner of the pmpmy,or my employees with wage u Noir mic compenadun,
and PrfesionsCdthe swctumismtNendcdo awdo lis ran apply owner
of Required Inspections
and property
Professions Cade:The Cam rectoas Littre law docs Int apply to r t owner is q P
pme enywyees.preords irepmv A•mprove who doe ss,chwmkh rro(rewthmugh his
awn ver,the
provided that such improvements in not ear ofc aroRnW for owner-
however,the building or improvementg said within an year ofcompletion.r dm owner-
builder will have Nc qWa of proving Nat he aid ret build o improve far purpose or
sal/e.).
12 1.u owner of she property,am memonvely contracting wish iiarsed cost ranors to
construct the project(Sec.7044,Business and Profession Cade:)The Comegerots U.
cense Law does net apply in an owner of property who builds or improv thereon,and.
who contract of such procs with a eantraccer(s)licensed Puuuam to the Contractor's
License law.
❑lam tie t er See B R P C for ddr reason
Owrcr, f1p am
YORK• COMPENSATIONS RATION
1 hcmby a . Penslty of perjury arc of the fallowing dolarado,tc
I ha m and will mai macctfiam of Covent b¢If-insure far Warler'sCumpen-
radan,u provided for by Seton 3700 of the labor Code,for the performance of she .
work for which this permit is Ismed.
❑I have and will maintain WortcYs ComPenaunn Iwrance,as required by Seton
3700 of she labor Code.for the performance of the work for which thin permit is issued
My warmes Compenanan Inumnce Cartier and Policy number am:
Carrier: Policy No.: '€'.
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE SANITA
(ITu ratan need nularde tplemd!fine Permit is forone hundred dollars(SIM)
less.)
I cenify that in the wrom ace of the we fa Mich Nis permit is issued.I shall not
corplWanypencininan ammuerse ayyb esti' r the 1J7�cri Compcnadon
Lam of California.Dam—! /— �/
Applicant
NOTICE TO APPLICA .ITI�TL aR�r matiq cnifica c of Exemption,you should
bmhwi comply
to the W en port Compc don previsions of Ne labor Code,you mwC
z ,z forthwith comply with men pmvisinn r Nis parmiysMil M deemed revoked.
Z'" CONSTRUCTION LENDING AGENCY � /
N
F— IMrwhich thi thatthemiasued(Sm. lending agcnry for the performance of
1:4W 25 dm work for which Nu permit is issued(Sec.l09],Civ.C.)
6W. Q Lender's Nam.
z Lenders Add.
U O 1 certify that I have rad this applicasin.end sum Nat the above info r.a..is
cant 1 agree to comply with all city and county ordinanms and sum laws relating to
pU building consnuction and herebyauNorir,reprsenarives alibis city to cater upon the
H Wahovc-mcnwned pmpeny for inrpectian purposes
(We)agree to save,indemnify and kap harmless the City of Cupcnino agues'
rg Iiabiiiaci.judgmens.casts and expenses which may in any way accmc against said City
U az in eomequenec of the granting of this permit
'—' APPLICA UN ANDS D Wn. MPLY WITH ALL NON-POINT Issued by: Date _'Z D-U6
SOURC TIONS.
Re-roofs
Sigdazum a(Applican nuacto Dam
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Willthicythm Cl yon future bpalCgacupaptrrwcor handle Heardoand Sa:ety
u dented io the Cupertino Municipal Cade.Chapter 9.13,and the HeaIN and Safety
cafe.Section35324)?
❑yes q/ All roofs shall be inspected prior to an roofingmaterial being installed.
Will
she applicant or future building aavPa.,urs equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harardou air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �Nu
I have real Lou hsrardms mamrialsmquinam under Chapmr 6.95 ofthe Califm.
nig 11a1N h SafctyCte,Section 35505.15533 am175534.1 understood thazif the building
dos riot cuncntl ha ant that it a my respesibi' m hairy the tccupant of the
require month mel rtoi ameol rCamoroccupanry. Signature of Applicant Dale
to anam ag.m D,m All roof coverings to be Class "B"or better
..,a, Community Development
10300 Torre Avenue
e✓` Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
4UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
�j(2O <O'7
OWNER'S NAME: PHONE # 00
GENERAL CONTRACTOR- FAX #
I am not using any subcontractors:
Signature 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
-
ner/Co tractor Signature Date
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35910060. 00
DATE ISSUED. . . . . . . : 12/20/2006
RECEIPT # . . . . . . . . . : BS000000037
REFERENCE ID # . . . : 06120107
SITE ADDRESS . . . . . : 10227 S DE ANZA BLVD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : VARDY SHTEIN
ADDRESS . . . . . . . . . . : 10227. 5 DE ANZA BLVD
CITY/STATE/ZIP . . . : CUPERTINO,
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : JOHN KIM LIC # 24859
COMPANY . . . . . . . . . . : ANGEL'S PLASTIC & NEON CO
ADDRESS . . . . . . . . . . : 495A MADERA AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 280-0907
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- ----------- --------- -- ------ ---------- ---------- ---------
BPSEWER SEWER SYSTEM 1.00 21 .58 0. 00 21 .58 0. 00
PPERMITFEE FLAT RATE 1. 00 38. 37 0. 00 38 .37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 59 . 95 0. 00 59 .95 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT
------------------
CREDIT CARD 59 . 95 MASTERCARD
---------------
TOTAL RECEIPT 59 .95 ,
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
•
CITY OF CUPERTINO 0(.01201 COQ
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
a59 -10 - 0(-00ae:
QO
Building Address: L
/01a 7 v46 ,,o - /otr,e--�
Owner's Name: P one#:
agloy (412 q (on
Contractor: Phone: License #:
✓r Ott 6e A &/H (--
Cont t: r�D Phone: Cupertino Business License#:
E `f 3 7
Building Permit Info:
//f,A T 'C ,fie/U/ Gr,' A-7,
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential ❑ Commercial
Cost of Project: 1 �sO —
•
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
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•