06050198 ---------------------
CITY OF CUPERTINOJ t'•'d s+r &. �a'- i '� '%
BUILDING DIVISION p RMIT �CUNTRA.CTQRINF`t?RMA,TTQ
BUILDING ADDRESS: ABLE SEPTIC "'RMRNO.06050198
MERCEDESZZ$00
OWNER'S NAME: PERMIT ISSUE DAM
BAYNES DEVELOPMENT ROGER 520 REED ST.
E: SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHI'fECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MMH
jOC LICENSED CONTRACTOR'S DECLARATION 1 Job Description
F 1 hereby affirm that 1 an licensed umkr provisions of Chapter 9(commencing P
?z�S{ with Section 10W)of Division 3 of the Bifid.and Profettims Code.and my licerueis
EE mfwuareaende�f9n Z L�» 67• L47S- INSTALLING A SANITARY SEWER SYSTEM LATERAL
o�n,ecl Omarsew /� CONNECTION TO MAIN LINE 171 -201 TRENCH
ARCXf1ECi'S DECLARATION
I I understand my plans shall to used as public mcorN
Licensed Pm(casionl
OWNER-BUILDER DECLARATION
iI bunchy art..that I am exempt from the Contra mos License Law for the
0 o fallowing masa..(Sector,7031.3,Business and Profusion Cade:MY city all county
S$ which mquim a Permit in construct,ales.borrow,dem isu.or repair any avumum
iy prior of its issuance,ohm requires the applicant formch Permit to file asigned summon,
< du"M411ccoscdpursuant tothcprovisions oftMConumimlLicence,Law(Chapter 9 Sq.Ft. Floor Area Valuati06415
€s (commencing with Section 7000)of Division 3 of Ne Businessand Profession Cash)or
r — that he is asrmp"themfmm and Ne basis for she alleged exemption.Any violation of
Section 7031.5 by My applicant for a permit mbjeem Ne applicant in•civil Penalty of APN Number Occupancy Type
Out mane than five hundred dollars(3X ), 34222045 . 00
❑1,umnerofte Nopmy,mmywploycowithwagosutha'umlcCo Peosdon,
will do the work.and,restructure 4 notimmnded or offemd tarsals(Sec.70/4•EastmanRe aired Inspections
and Profession Cade The Commodore,Liman Law tan Out apply m an Owner,of q P
Own emy who builds orimprovea h Impr and who ar easuch work n;m..0or Wvugb his
awnemployees,psmlded Narove improvementsarc not IntendedofoRemd for moon,
however.the Wilding o improvement ta mid within an year mimpone for themoment,
of
Wilder will Mw the burden of proving that k did no,build or Mprow for purpose of /••�
rule.).
❑I.as ower ofij the property..B sine s and cenbaminal with licensed mnuxton u V
Convect d project(See.7014,Business and property
who
Cache)The C s themon. sad
cease law can not apply a is ower of pramr(s who Wilda or improve Norton,and
whocontractsLace ran such projects with a cantractar(U Ikeved punuam m th<Conuas3oA '
0 loss
law.
❑lam uempt uralm See ,BdPCfor use mason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby aRired under penury of perjury ore of the fallowing doelarWon:
I have and will maintain a CeNfinuaf Consent to aelr-Inman for Wohels Compen-
mean,as provided for by Section 3700 of the labor Code,for Ne pend...of the
work for which this Porch is blued.
❑1 have and will maintain Workers Compensation Imam¢,as inquired by Section
3700 argue Labor Code•for the performance of Ne work An,which this pemi14Issued.
My Workers Compenulen Ivunnce ureter and Policy number am:
Cartier. .� IA6, A/9G`i Polity No.: OMSl90II
ERTIFlCATE OF E% PTION FROM WORKERS
COMPENSATION INSURANCE
This seNOn need round completed Ifft permit 4 forme hundred dollen($1001
or lea)
I century Nat M the Performance of the work for which this Permit 4 Wood.l shall tent
employ any person in any man ierso as N become subject in the Workers'Compensation
Laws of Califomm.Duo
Applicant
NOTICE TO APPLICANT:If,after making this Cenifiale of Esempton,you should
become subject m the Workers CamPoasNon provisions ser Ne Labor Code,you most
OZ foMwith Comply with such prevision or this permit Nall M deemed mwked.
z CONSTRUCTION LENDING AGENCY
t-t I hereby affirm that Nem 4 a constructed lending agency for the Performance Of
!�> the wells for which this permit In blued(Sec 3097.Civ.Q -
0 Landers
z Name
] Lenders Add^:•
U0 I Coldly shall have read Nis appiiuton and state thas the above mfomtNon I.
Ig,F corrin I agme in comply with all city and county ordinances and state laws misting In
0U building construction,and hereby authorise Miescnutiws of this city to enter upnn the
U above-mentioned property fill inpcdonPurposes
gL (We)agme to save,indemnify and keep harmless the City of Capcldna again"
,-yy Iiebilitigjudgnams.emta ando,, ...which may In my way eeemc again,said City
C.)z in conaegcenCo of Ne gmntng o!Nb perml".
•+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR FAULATIO S.
/LVIP S_ srJoc Re-roofs —��
Slgmam afnppl tlComrecmr
—
XAZARDOUSS MATERIALS DISCLOSURE Type of Roof
Will the applicanu or future building occupamnme or hurdle ha eadoos material
a defined by the Cupertino Mu pal Code.Chapter 9.13.and the Health and Safety
Cale•Section 255320? All roofs shall be inspected prior to any roofing material being installed.
❑Yen No
will ftapplicant Or rum buildingaaupant um equipment a devise which If a roof is installed*thout first obtaining an inspection,I agree to remove
it hanmaos air mnuminmu u donned by Nc Bay Area Air Quality Management all new materials for inspection.
District?
❑Yrs Nu
1 have mad the hammwe matetals requirements under Chapter 6.95 ofthe Califor.
nia Health d Safety Code.Led.25505.25533 anal 25534.1 undenund that lftha Wilding
dons not currently have a unit.the It 4 my responsibility in notify Ne oecupan"of the
requirements which nualpe met prior to issuance of a certificate of Occupancy. Signature of Applicant. Date
Owner or tacodayent Dow
All roof coverings to be Class"B"or better
ate"
CITY OF CUPERTINO
�m 1 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 34222045 . 00
DATE ISSUED. . . . . . . : 05/23/2006
RECEIPT # • • . . . . . . . : 34526
REFERENCE ID # . . . : 06050198
SITE ADDRESS . . . . . : MERCEDES RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BAYNES DEVELOPMENT/ROGER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : ABLE SEPTIC
CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407
COMPANY . . . . . . . . . . : ABLE SEPTIC
ADDRESS . . . . . . . . . . : 520 REED ST.
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95050
TELEPHONE . . . . . . . . : (408) 377-9990
�EE 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
{ / Cupertino CA 95014
' Telephone(408)777-3228
cl OF Fax(408)777-3333
4UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
CAa�?X wi/ ,✓eledpk v tr;hno 025oSal �l
OWNER'S NAME: (act S I of r v PHONE # Olc `132 - S',Wr
GENERAL CONTRACTOR qlx s FAX #
I am not using any subcontractors: l La S- .23)0&
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
Owner/Contractor Signature Date
OL¢0501q'b
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# ZZ O� I� Date:
Building Address:
- aabvO MercedvS rd . Cv ✓finb
Owner's Name: Phone#:
rvt ®t�1v rne✓rf ila, �/3�. -f�d8 $m
Contractor: Phone: License#:
s} �G2SEPrlC 977-'x990
6'I747 S"
Contact: Phone: Cupertino Business License #:
671£.V &V61A/ 377-799v
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
IMslul/�� c� $p+,r dtwcr S turn teckN 4-1 eom~c�'on do w.nw n l,r�e �� fnnah
Residential Commercial ❑
Cost of Pro
jgct:
6, yrs=
Qty. if
A licab 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