05070101 CITY OF CUPERTINO '�' � : �� 'Wit#
BUILDING DIVISION PERMIT CONTRALTO INFORMATION ;:
BUILDINGADDRFSS: WALTER MOBILE HOME SERVICE 1111 N'05070101
W NER'S NAME: PERMIT WOE DATE
ERMA CH_APPEI,L _-
E. SANITARY N 2 ONTROL 10. '
ARC HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
2 p Zo LICENSED CONTRACTOR'S DECLARATION Job Description
jw,C 1 Mreby affirm Wei I am licensed under proviimu of Chapter 9(commencing
ou wiffi etion7IX )of Division3of We Busi �ore ed_atMmylieenseis
eor'n� FRALED in fuse force dna cited. Y i REPLACE MAIN WATER �pRppppp
jZ Liccna Cl Lit. E®
r w Data I C-domm or
4O s ITECI'S DECLARATION u
l� 1 Ls■Ly
a IunMrxu my ���hall =abcdupuMic records
g o,-
Licensed Pmfcs ILDER 2005
0 s OWt� RBUILDER DECLARATION /
.�i y 1 tensity strum that(em exempt from the Commodes Licena law far the
00 following mason.(Section 703 1.5,Business and Professions Code:Any city or county
which acquires a permit to ennswc0 alar,improve.demolish,or repair any structure
z i prior to its issuance,also reclaims the applicant for such permit to file a signed summer,
ss that he is licensed pursuant to the provisions of McContractor rLiccnuLaw(Chapter 9 Sq.Ft, Floor Area alua[ion
xF$ (Commencing with Section 7000)of Division 3 ofth=Businessand Professions Code)or
Nat M as exempt merefrum and the basis fm the alleged emmption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3'ARIN Mk2i cr00 Occupancy Type
not more Wan firs hundred dollars($500).
❑1,u owner of Oa prepcny,army employees with wages m Ihcir sole compcnation,
will do me work,and theswcma is not intended or offered for sale(Sec.7044,Business Required Inspections
and Pmfessimro Code:Time Conuamoes Li.Law does tat apply a as owner of q ns P
pmpeny who builds or improves thereon,and who doessuch work himself or through his
own empleyew.provided thauuch impmvemanu as not intended oro@real for We.if,
however,the building or improvement is mid within am year of completion,the owner-
builder will have We burden of proving Wm M did not build or improve for purpose of
sale.).
❑h as owner of da property,em udusively contacting with licensed eonuacma to
Consumer me project(Sec.70,14,Business and Plemmons Code:)The Conumhm'S Li-
c re law dm not apply to an owner of property who builds or improes tM¢on,and.
whocommets for such projaas with a con racmr(s)liaised pursuam to the Contractors
License Law.
ri I am exempt under Sac .B h P C for this reason
br Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury cm of me following decluation e
❑1 have and will mainuin a Certificate of exceed to self--insure for Worker's Canadian.
sation,er provided for by Section 37W of the labor Code,for the performance or the
work for which this permit is issued.
1 have and will mainuin Workers Compensation Insurance,as mquirced by Section
37W of the labor Code.for We performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number me-
Cyte'.. Policy No.:
` CERTIFICATE OF EXEMMON MOM WORKERS'
COMPENSATION INSURANCE
This action need not M completed if da permit is formic hundred dollars(SIM)
nr lcsa)
I cenifv that in the perfinmanee of me work for which this Permit is issued,l shall not
employany person in any mmncfmssabm a mbjecjm Me Worker,Compensation
Laws of Ciif rain.one,
Applicant /In
NOTICE TO APPLICANT-117-after making this Ccnifcaa of Exemption,you should
become subject be me Workers Compensation psovuioau of We Labor Code.you muse
�Q forthwith comply with each provisions or this permit shall be deemed revoked.
Z M CONSTRUCTION LENDING AGENCY
[-�� I hereby affirm that there is construction lending agency for the Performance of
O: the.,it fur which this Permit is issued(Sec.3097,Ci,C.)
QLendces Name
z Lender's Address
U C) i certify that I have read this application and sure that the rebore information is
U.;: coram I agree W comply with all city and county ordinances and sum laws relating to
0U building construction,and hereby amhoma representatives of this city a enter upon the
r W aivve-mono ud pmpeny for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupcnino against
i y liabilities.judgmena,costs and expenses which may in my way accmc against mid City
U to conugmnce of We granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL ONS.
/d IFfGa. 'f���'� Re-roofs
Signature ol'Applicamiconormlor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will 0a applicant or future Wilding occupant Hoa or handle hazamous material
as defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
.
Section 85324)7 \ All roofs shall be inspected prior to an roofing material beim
❑Yea �Nm, P P Y g being installed.
Will the.ppfda i mr mWrr hooding m=avant mm equipment or devices winch ' If a roof is installed without first obtaining an inspection,I agree to remove
emit Immadous air conuminana as defined by the Bay Area Air Quality Management all new materials for inspection.
Disuict7
❑Yes / Nu'
1 hoc read the Noardous materials requirements under Chaparti.95 of the Califor
ma Hcal"Safety Code,Seetiom75505.35533 and!25534.1 undersand mztifNe Wilding
does net Carmody hate a tenant Net it u my asposuihility m notify the<upmt of the
2yuimmena which mus act poor m issuance ofd Coniferous of Occupancy. Signature of Applicant Date
2rPA 7-r'8-OS
Owner ser amhonvad timid DateAll roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
/�78o God
OWNER'S NAME: 207ac-- ((,4 p c /( PHONE # g Z -z z g
GENERAL CONTRACTOR: FAX # 9 Y6 i S�,,Z 3
I am not using any subcontractors: dIrl 7 - /It--0`f'
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
Own Contractor Signature Date
CITY OF CUPERTINO
IFem 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 2
Sec: Twp: Rug: Sub: Blk: Lot:
APN . . . . . . . . : 37515024 .00
DATE ISSUED. . . . . . . : 07/18/2005
RECEIPT #. . . . . . . . . : 30407
REFERENCE ID # . . . : 05070101
SITE ADDRESS . . . . . : 18780 LOREE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ERMACHAPPELL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : WALTER MOBILE HOMES
CONTRACTOR . . . . . . . : WALTER TEJADA LIC # 25023
COMPANY . . . . . . . . . . : WALTER MOBILE HOME SERVICE
ADDRESS . . . . . . . . . . : 10275 MORETTI DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 996-1986
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 83.16 39.92 0.00 39.92 0.00
BPERMFEE VALUATION 200.00 83.16 0.00 83 .16 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BPWSVCS WATER SERVICE 1.00 9.00 0.00 9. 00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 170.45 0.00 170.45 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -__-_---_--_____-_
CHECK 170.45 5368
TOTAL RECEIPT 170.45
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 106 SEWER & WATER
507 FINAL PLUMBING
CITY OF CUPERTINO
®
aRREPIPE/SEWERS/BRAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM .
APN#
Date:
Building Address j,F70C-,0 GO Z U —c-
Owner's Name: Phone#
o7 gq
Contractor: AW,-474Phone: License
z #: 76 (r/(- f7 7
z
Contact: Phone: Cupertino Bus ri ss L cense #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential b Commercial ❑
Cost of Project: Oa
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
BENERGY Energy BUILDING
BUSLIC Business License BUILDING