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06030101 CITY OF CUPERTINOA> #a '4+x:aN¢ b'k+s- �'-x;% '' '> BUILDING DIVISION PERMIT �,�CONTRACTOR I1VFURMATIOI : BUILDING ADDRESS: PERMIT N0. 22931 LONG DOWN RD WNER'S NAME: PERMIT ISSUE DATE SAMIR DSIR 1000 N RAND RD, #112 03/20/2006 HONE: SANITARY NO. CONTROL NO. (866) 293-3031 ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 300 LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 em licensed under provisions of Chapter 9(commencing with Section 7")a(DivWon 3 of W Buoncss and ProfessionsCade.sed my license Is in full to=and off ueg REPLACE HOT WATER A W TALL 12YR ppz License am _ Dam Camnemt F ,t in'ECTSDECLARATION �� 2UU6 > I nkeaaod my plane ehsilMusedaspuMic mrnrm BUILDING and Lkenscd Pmfcasional OWNER-BUILDER DECLARATION C O Z I hemby a(frm a n 1 em eBusin rrurn an W CnntractCo e:Anse Lew far tde O o following mason.(Section IID str Business and ve de Toro Code:Any city o lcounty �'CJ O(] COO $ff which requires a permit m cnnnmcL alter,improve,demolish,ea repair any Nuemm aiP„' poor at its issuanec,2110 mgkres the applicant forsuch permit to fila A signed sratemem < Net he 4 licensed pursuant N the provisions of the Conmcmes License Law(Chapter 9 Sq.Ft.Floor Area Valuation (commencing with Section 7000)M Division 3 of the Business and Preimmu Cade)or S that he 4 camPr turnaround and the basis 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 more thin five hundred Man($500). ❑L asowuer of t e property,ormy employees with wages astheir sok compenu0on, will do the works and th.macnm ismalnunded oro@sd fmam(See 7044,Business Required Inspections and Profaeimu Code:The Contractors License law does not apply Ine an owner of 9 P property who builds crimproai Wmon,andwho doessuch weak himsolfor Waugh his awn employee,provided that such Improvements.aminterked eaoRened far sale,U. however.the building or improvement is sold within oue year of completion,the owner- buitder .will Mw the burden of proving Wt the did not build or impraw for purpose of ate.). ❑1.as owner of the property,am exclusively contracting with licensed conuamrs to construct W project(See.7004,Business and Professions Cade:)The Carman'Li- came law does not apply so an owner of property who builds,or improm Wrean,and, who contrM4 Tea such Projects with a conunnaKs)licensed pursuant to the Contactors License Law, ❑1 am exempt under Sea. .B k P C far this mason sonar Dae WORKER'S COMPENSATION DECLARATION I hereby eMan under penalty of Farrar,arc of the following declenfions: ❑Ihawendwillanainuina CeNfiauaf Coventuself-ImurefmWoraersCompen- moon.u provided for by Section 370D of W Labor Coda,for W Performance of W work for which this,permit is issued. have and will maintain Worker's Compensation Insurance,a required by Section 370D of the Labor Code,for um performance of the work for which this parrot,is Issued. My Wmlmes Compensation Insurance artier and FOR,number m: Carrier: It-FtlkC policy NO,:we'S4ZIg4d CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE CThts section n and ara Wcompleted lithe perch 4 forane hundred dollen($101) or Mas.) I certify that in the performance of the work for which this permit 4 issued.I shall not employ any person in any manner an u in become subject m W Workaa'Comp tussis n laws of Cwifomu.Dam Applicant NOTICE TO APPLICANT:If,after making chis Onlircno of Eacmption,you should become subject to W Workers Campensation pmvitions,of Ne tabor Cade,you must ,JQ formwith comply with u such provisions or this permit Ise returned ewked, Z ti CONSTRUCTION LENDING AGENCY [r I hereby arthro uses them is a comuucuon lending agency for me perturmame of ai the work for which this Permit is iuced(Sec.3097.Can.C.) G Q lenders Nme z Lenderss 's Addre U0 i certify dust I have mad this,appliadan and sum that W above InformaWn is Ig,P correct.l agree to comply with all city and county ordinances and sum laws slating M 0U building construction,and hereby authorize reprmenutim of this City to enter upon aft W above-mentioned property for inspection purposes. (We-)ague to ave,indemnify and trop harmless W City of Cupertino Against rr rrA Iiebilifies,judgments.amts and expanses which may to my way accrue against said Oty YJ 7 In consequence of tic gmnting of this Ismail. r1- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date S URCE RECULATT NS. Qac 3 2�-19p Re-roofs Signe um or ApplicauConuavor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant stare or handle haamdous material as donned by W Cupertino Municipal Cade.Chapter 9,12.and W HW u and Safety Cedes,section 25532(8)7 All roofs shall be inspected prior to any roofing material being installed. go ❑Yes IfkNo Will W applicant or future building occupant esu equipment m dCVlees which If a roof is installed without first obtaining an inspection,I agree to remove emit MOmm i air contaminants u darned by the Bay Area Air Quality Mansgemcm all new materials for inspection. - District? ��''"" ❑Yes, ZNvu 1 has mW the hda vars materials mqutsmens underChapur 6.95 ofthe Caulor- n4 Hesith g'.Safety Cam,ScNats 25505.25533 and 25534.1 undeamnd dust if W building data Trot currently have a u um,the It 4 my responsibility in nodfy ore occupant of the a mmenu soman man be mmprior ro issuance of a Coni ar aapacy' Signature of Applicant Date Owner or authorized agent Dau �� All roof coverings to be Class "B"or.better CITY OF CUPERTINO •m 5 of 5 PERMIT RECEIPT OPERATOR: suem COPY # 3 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34240009.00 DATE ISSUED. . . . . . . : 03/20/2006 RECEIPT #. . . . . . . . . : 33636 REFERENCE ID # . . . : 06030101 SITE ADDRESS . . . . . : 22931 LONG DOWN RD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SAMIR DSIR ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2682 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 • FEE 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 METHOD OF PAYMENT AMOUNT NUMBER _________________ ____________ --______---_______ CHECK 420.10 21041 TOTAL RECEIPT 420.10 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ________ ____-------------------________ 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING Community Development l a10 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 SCUPEkTINO Building" De artment JOB ADDRESS: PERMIT # 2-2c131 0 o66 Z0 �o / OWNER'S NAME: ' ; PHONE # 74 p R '- GENERAL CONTRACTOR FAX# t4 C1 Lf 5- I 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 2 -T o l Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO WATER HEATER CUP VINO PERMIT APPLICATION FORM G �(�3�I/b/ APN 3yDate: a yU oa U6 Building Address: Un, n kipw, Q- Owner's Name: Phone#: O rn �C H bA LI-1 0 Contractor: 0 W a t.A. rw� , License#: u�y XI-C II_ 60014 6o O Conta t: PI'S-3 5 L- 0 65-7 Cupertino 3usiness License #: 710 Buildi ig Permit Info: Bldg ❑ Elect EJ—' Plumb Mech 0'( Job Description: Resid ntial NA Commercial ❑ Cost of Project: M Strapp A LJ On Platform 0 Bonded New cation ❑ Replacement ❑ Qty. if Appli,.able Fee ID ion Fee Group BPWHEATER (Water Heater/Vent BUILDIN / PPERMITFEE ermit Issuance LUMBING BENERGY Energy —trm—mr— BUSLIC Business License BUILDING •