00040063 (2)CITY OF CUPERTINO _ PERMIT No'
BUIL&NG DIVISION PERMIT . CONTRACTOR INFORMATION: 0 00 ^b'3
BUILDINGADDRESS:
a , g'3 -t, L j�rf�.fif 1(`.raOP /�(ui. rEiy nr SANITARY NO A'AT�%SUBoM� AL DATE
WN 'S NAME 0a, w6z/ �.OJ
//Y''��` N/C CONTROLN
o
C a/ ❑
PHONE : -
4as . 3 Cc 7-C
ARCHITECT/ENGINEER BDLDINOPERMITI -G
Z O N LICENSED CONTRACTOR'S DECLARATION
o z - sew 1 httebr .Term neat l un hamxw acR prMvirim,a Mr Chapter 9 (mnmuttcmg Job Description ( ,
F=y ivt$ecnon?000)ron Met
under
hapten 9wr"
gYf'.c in full forceaac ecr •
S K w U Lianu We M •Ire '
gH Dme ConDECL r'a
'ARCHITECTS ARATION
vq�qaJ� I.ndersund my plan ehJl banned as public records
i.E o Licensed professional
M m OWNER -BUILDER DECLARATIONexe-
z, G I hereby .Rn met I am mpt from the Contractors License Law fm the '
s ❑ following moon. (SM660 ]031.5, Bmimss aro Profession Code: My city w county -
wwhich requires a Permit m combuct, alter, impmve, drowlish, or m sweture
d s repair y Sq. Ft. Floor Area _ �Jaluatio
pdotoits iensedF alsod1.th MmoisMe plicaot foreachpemdt toicense Law
(Chamrnt
Net he is licensed punuentto We proviJoueof Me Contractors License Lw(Cheprer9
(cam a is me with sectfrom mal Me lawafom3 Meths B ed exam tons. Any viccnx)or APN Number Occupancy Type
that io is exempt therefrom and the basis tae Ne alleged exemption. Any vloafion of - ) p }r yp
Section them by any applicant for a permit subjects da applicant to a civil penalty of
not more Nen five hundred dollar . -
❑ 1, as owmr of the propeny.mmymplployena wiN wagnu Meir voleconpenutian.• Required Inspections - and
profession,
Code The court ie no inaacpd w Law
dos am, "Ply to . B.Jmss
'aro arty wlotn Cade: The ant Marro Liana law dens nw apply to lf comer gh
hisown whooymi, or Woman M tbemoq and who dens an wok himself or through
his own employeese provided Na such impros sold v ace mminaaced i ofrertd for
urot,tsowevet NchuilMeburin of Move
is did act
Wild
inimarmfimprove (in
• - ,
owneo-Wilder will have Ne burden of proving Net he did not build or improve fm pact'
you a ememe m
Q r en memer of the progeny, senexclusivelysaend Protracting with ECeneed contractor .
conserver rhe project(Slyu;tO,ader of
Professions Code:)Thes. theton. nd _ 1(
• <enu Lew dwa Doe apply to tee owner of propemy, who builds or impravm Nmerv. end
who contracts for such pmjmu with a comracmr(a) licensed purauent to Ne Comracrors 0
Lt.. law. „
❑ I am exempt under Sec. . BiI:PCwrMisrwon-
wmr Data
WORKER'S COMPENSATION DECLARATION
Ihcrtby.MmunderpeneltyofMriu M ofehefullrwingde tiom:
I,� ❑ I have and will nomenunecmar...Mfconnedto self -insure forWorker'sCompen-
smon, as provided for by Section 37W of Ne LaWr Code, for the performance of Ne
work for which this permit is issued. '
❑ 1 have and will maintain Warksi r Compensation Imurace, as required by Section ` - -
my orknesCmCodgfon Insurance carrier the number
e: peemir is ieawo.
My Worker's Compensation Insurance carrier Mao Policy number are:
^
CERTIFICATE OF EXEMPTIOFROM WORKERS'
COMPENSATION INSURANCE
(This accounts need nm becompinedifNc pemitixfwouehuacmddollan (5100) •
lecAifr0!nintheperfo ceofthewmkforwhich Nixpesmirisiaued,ls alI -
... employ W, person in any anam �� bs/omea.b,. to Ne Workers' Comped-
-1100
Iawr,et[mf�F., Data !� O _
Applicant ax
NOTICE T6RP: 1 a/ far makang this Centficam of Exemption, you should -
b<coma comply
the Worksro CMmpeor this provisions of the 6ebo Cade, you mud a
forthwith comply with such provisions or this permit Jell ac decreed revoked. -
CONSTRUCTION DING AGENCY
0 LENI hsrcby a(fim that Nes ie a conawNon lsacing agency for the perfommi a d,
%j- Ne work forwhich this permit is issued (Sw. 3097, Civ. CJ
•^�y Leaches Name
ai > lenders Address t
Leel � . 1 certify then 1 have reed this application and sure that Ne shove information is
z correc
d . t 1 agree to comply with all city and county ordinances and auto laws missing to '
r-1 z building ccnawctim, and hereby mthodumpresenativer of this city to enter upon Ne a
�•% .hove-rommncd pmpedy for inspection purpnan. - • `f `
W Fw (We) agree m nave, indemnify end kap hamlear the City of Cupertino against
f, liabilities, judgmem, costs aro expenses which may in wry way achene against said City
�y W in c......eme of Ne grouting of this permit t
F p" APPLICANT. UNDERSTANDS AND WILL COMPLY WITIi ALL NON.P01Mf Y
V Z SOURCEREGULATIONS. - k
SignatureofApplicenUCon- Due
HAZARDOUS
MATERIALS DISCLOSURE
• Will the applicant wtmurefuturc building occupant Burt whmdle hazardous material Re -roofs '
as defined by the Capron. M.vcipel Cod, Chapter 9.12. end the Helm and Safety Te of Roof .
Code, Swim 15531(.)? Type
Ely.
Will Meapphcantwfuture Wilding waupenruse aq.ipmen,ordeviceswhich All roofs shall be inspected prior to anyioofing material being
oris hamardoua air containments as defined by the Bay Arca Ah Quedui Management installed: If a roof, is Installed without (first obtaining an inspection
°'xb'"'
❑Yes /y"(.oI agree to remove all new materials for inspection. Applicant
Ihave.W Me hazardous materials mquirentmns under Chapter 6.95 of the Cali- undeLiLwids and will comply with all non point source regulations.
fomu Health & Safety Code, Sections 155(15.25533 and 25530.1 understand Chet if y, r
building does no, currently have a knenL that it is any responsibility to notify the occupant
mems which met pdorm issuance of.cerifscea of cu ry.
�—r ii m0 Sign Lure of Applicant Date'
'Ownero mixed gem Daa.-
All roof coverings to be Class "B" or better
0FFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
11 BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rug: Sub: Elk: Lot:35624021.00
INVOICE DATE......: 04/11/2000
REFERENCE ID # ...: 00040063
SITE ADDRESS .....: 21832 LINDY LA
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: PAUKEN DONALD J AND ANNE R TRU
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4813
CONTRACTOR .......: LIC #
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP ....
TELEPHONE ........:
FEE DESCRIPTION CHK
BPREPIPE
P
BPWHEATER
P
BUSLIC
P
0ITFEE
P
TOTAL FEE PAID -TO -DATE BALANCE DDE
108.29
9.99
90.00
35.52
243.80
VOICE ID DESCRIPTION
........ ............................
106 SEWER & WATER
301 ROUGH PLUMBING
502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
4�
----------- -----------
0.00 108.29
0.00 9.99
0.00 90.00
0.00 35.52
0.00 243.80
VOICE ID DESCRIPTION
........ ............... ....:
202 UNDERFLOOR PLUMING
302 TUB & OR SHOWER
506 GAS TEST