06030097 'CTTYOFCUPERTINOccea,>
BUILDING DIVISION PERMIT ,kC�1l''ixRt1CTQR.INP'U 'Inlq
BUILDING ADDRESS: PERMIT N0.
7519 DUMAS DR
�\ OWNER'S NAME: PERMIT ISSUE DATE
JILL HOLB 1000 N RAND RD, #11203/20/2006
ONE: SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
o LICHNSED CONTRACTORS DECLARATION Job DDSCrIpt100
1 hereby affirm that 1 am licensad under previsions of Chapter 9(commencing
with Section.7M)of Division 3 of the Business and Fiordland..Code.ander licence is
4�q imm�ta sander q p y REPLACE WATER HEATER/7 GALGAS
■CTALL 6YR
:J? Damnre Cleo —CunuecmO�OO� � lT ��!®
3
ARCHITECTS DECLARATION
I downward my plane'hail he used as public¢cords
=CCC.
Licensed Professional APR il� 2006
OWNER-BUILDER DECLARATION
1 hemhy airline NUI 1 am exempt from the Commences License Law for the
c o O following....(Section 7031.!,Business and Profession;Code:Any city or county $500
3$ which requires a permit W construct.alter.Improve,demolish,or repair any structure
Prior an itsisume,arm requires the appimam for such permit to file asigned summem
< that he is licensed pursuant to Ue provisions of NC Communes Liennm Law(Chapter 9 Sq.Ft.Floor AreaOn
(commencing with Section 7000)of Division 3 mf the Business and Pro(cuions Code)or LF
.. Nat he Is exempt therefrom and the bub for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of umber Occupancy Type
not mart than five hundred dollars(SSW). -
❑I,u owner of the pmpeny,or my employee,with wage at their sole cempenadon,
will do the work and the saumum is not intended or offered for sale(Sec.70th,Business Required Inspections
and Professions Cade:The Canuuanply as ns
nor's Licee law does not apan owner of q p
property who Wilda orlmprmve Uemon.andwho doesaueh work Incrai through his
van employes,provided Met each Improvements sum nottnmtded oronBm td for els.if.
however,Ne Wilding or improvement is said within one year ofcampletion,the Owner.
builder will have Ne human of proving that W did not Wild or improve for purpose of
veto.).
❑1,at owner of the property,am combatively cantraning with licensed mrso moa to
construct the project(Sec.7014,Bwinw and Profession Cade:)The Contravenes U.
ane Law does not apply W so owner of property who Wilds or improve Moment,and,
who contracts for such project with a conuactorm)Ilansed pursesm to the Co ruamoM1
License Law.
❑1 am exempt under Sec. .B h P C for this reason
nu
—Dam
WORKERS COMPENSATION DECLARATION
I hereby alRnm under penalty of perjury aro of the following decluatiom:
❑1 ham ad will msinuin a CeNOnte of Covent W,elf-ilium fw WonrkeeaCompen-
uUon,u provided dor by Section 3700.(the labor Codefor the performance of the
work for which this permit Is issued.
I9 I haw and will maintain Wokah Compematian Insurance.as required by Socdon
3700 of the labor Coale,for Ne performanee of Ne work for which this permit is Wood.
My Wnr agcke,5�Ca^rripp^mostian Ines.tinier and Policy number am: ....kk�40/5
Cartier.fT'13 tiC^ PolPolicyN.AsIL' 142-1 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseed.reed not W oompleed Inho Permit Is far.hundred dallan($101)
or Ives.)
I anifY that In the perderma.x of the work for which this Permit Is issued.I shall not
employ any person in any manner so as W Income subject to Me Workers'Campeneation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL arm,making this Ccnificam of Exemption,you should
become subject W the Workeh ConmPmuNan provisions of the LaWr Code.you must
r,Q forthwith comply with tech provisions or this permit shall the decreed revoked.
Z a" CONSTRUCTION LENDING AGENCY
I hereby IMM that Nem is.construction wnding,gaey for Ula Performance of
C
the work for which this permit is ivad(Son.3097,Civ.C.)
W t7 Lenders Name
az Lender's Addmes
U 0 1 certify that 1 have read this application and saw that Me shove Information is
D.F contact I gree to comply with all tiny and county ordinances and sum laws matint W
OU building construction,and hereby amhodm represenmihm of this city to caner upon the
W ¢hove-mentioned property for inspection purposes.
py (We)agree to pve.indemnify and kap humleaa the City of CupcNno.,,Joel
�..i VI liabilities.judgment,ounce and expenses which may in any way accrue&joint said City
U in comegance of the granum,alibis penult.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCg REGULATIONS.
Re-roofs
Signature of ApplianUCommenor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant nom or handle hosardoa martial
u defined by the Cupertino Municipal Cade.Chapter 9.I2.and the Health and Safety
code, ..zss3z(.)7
0 Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupam use:equipment or cm,me;which If a roof is installed without first obtaining an inspection,I agree to remove
M
ark hanrdous air anmmimms u dc0ncd by the Bay Arta Air Quality Ma.,cmcnt all new materials for inspection.
istrict?
❑Yea ON.
I have read the buu
�ndmmawrials requirements under CTupierd.95 of the Califor.
iaHalth k SafetyCade,Samwm253113,25533 am125534,I understood!that ifthc Wilding
not cuncnlly haw a mnanb responsibility W t.that it my resnsibility andfy,the occupant of the
qu1
iremyents which must be met Prior W iuvance of a CerufoaW of Occupancy. Signature of Applicant Date
_SJ_'S`�eQ�a.w All roof coverings to be Class "B"or better
Owner or authorimda cm DaW
CITY OF CUPERTINO
1 of 5 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35924046.00
DATE ISSUED. . . . . . . : 03/20/2006
RECEIPT #. . . . . . . . . : 33636
REFERENCE ID # . . . : 06030097
SITE ADDRESS . . . . . : 7519 DUMAS DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JILL HOLE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4310
RECEIVED FROM . . . . : METRO MECHANICAL
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : METRO MECHANICAL INC
ADDRESS . . . . . . . . . . : 1000 N RAND RD, #112
CITY/STATE/ZIP . . . : WAUCONDA, IL 60084
TELEPHONE . . . . . . . . : (866) 293-3031
QEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ,
__________ _____________ __________ __________ __________ __________ __________
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 .86 0.00
BPWHEATER PER HEATER 1.00 10.79 0.00 10.79 0.00
PPERMITFEE FLAT RATE 1.00 38 .37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 84 .02 0.00 84.02 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
#UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
OWNER'S NAME: PHONE # L(Q- 8 k
GENERAL CONTRACTOR: FAX# (o t 4 9? tE
I am not using any subcontractors: 3
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 �.�,�Q, c ,I(A 2 7 4n
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile\v' y
• L C J -2-0 t
Owner/Contractor Signature Date
- CITY OF CUPERTINO
•
WATER HEATER O1o63�7�
CUP VINO PERMIT APPLICATION FORM
APN It 35 Date:a a _ob
Building Address:
Owner's Name: Phone#:
arl�- S - r s�
Contractor: License#:
Conta t: %S-3 S6 -Cab s1 Cupertino Business License #:
• 031 Z-`T 9
Buildi ig Permit Info:
Bldg ❑ Elect Plumb Mech LY
Job Description: 1
—iTesidcntial M Commercial ❑ \
Cost of Project: (�
"l S�j b0
• Strapp d On Platform Bonded El
New cation ❑ Re lacemento
Qty. if
Appli able Fee ID cri tion Fee Group
BPWHEATER ater Heater/Ven BUILDfW
PPERMITFEE Pluffiffint Permit Issuance UMBING
BEN ERGY Energy IMIEUING
BUSLIC Business License BUILDING
•