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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 •