08070006 CITY OF CUPERTI77 17,,F ° "� n,7
BUILDING DW.ISION. PERMIT CONTRACT9,RINFORMATION g
* .'AW+z�°z
BmLp/l6Gppl�c NPERMIT NO.
ORTHBROOK SQ ALL VA1,LEY ?LUMBING 08070006
OWNER'S NAME: PERMIT ISSUE DAIS
1ZABETH KOGUT 3345 SELDON CT 07/01/2008
HONE: SANITARY NO. CONTROL NO.
ARCHn ECrrENGINEER: BUILDING PERMIT INFO
WTR HEATER REPLACMNT aO EPLUUMMB 0
I o o LICENSED CONTRACTORS DECLARATION -
1 hereby affirm that I am ibsused under Provisions of Chapter 9(mmmencing r Job Description
z with section 7")of Division 3 of NC Business and professions Code.and my license is
in full forts and eff
License Class lY.0 74
Fp Dan Camanor _
p{7W ARCHRELTS DECLARATION
m e I understand my Plans shall be used an public records
JaU
�aG Licensed Pmfcssums!
5OWNER-BUILDER DECLARATION
I hereby olRnn that I am exempt form the Contractors License Law for the
o following remen.(Section 7831.5,Business and Pmfcssina Code:Any city or county
Isi i., iuiva aperosilmci=ft alter,imparts.hp W,mcasiganysmmure
5zr primmin tensed pursuacquires Provisions
sof for smM1permitmnlem Lnedstamment
F€Qthat he incingwitPuranion7")of Division 3 the Canuxwr's Licenselian(Chapterodc)or Sq.F[. Floor Area Valuation
ysi $ that be ac
(commencing section Ca basis or ortheeged exsontl Profeu,a is Cai ..(
y�—
that he V ucmpt Nerefmm and Ne bats for dm alleged exemption.Any violation of
Scoden 7031.5 by any applicant for a permit subjects than applicant Io a civil penalty 0( APN Number Occupancy Type
neo mom Nan five hundred dollars(S50 B. P Y YP
❑1,as owner of the property.Or my employees with wages an Nersoin compeneauon.
will do the work,and the ewctme is rmlimen caul ounfrered formic(Sec.704/,Business
and Pmlosemn Cede:The Dmtbk mre U.law dna tet.pply to an owner of Required Inspections
Property who buildswimpm ss thereon.and wW doessueh workhimsel(orllwugh his
we employca,provided thaauch impmvemente are not immtled meffered for We.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will Ware the b rmeo of proving Nat he did not build m improve for purpose or
sale.).
❑1.as owner of dm pmpeny am exclusively contracting with licensed centrumn to
Construct the project(Sec.7044,Business and Profession Cade:)The Conmcmr's U. .
Comm Law docs not apply m an owner of property who builds or improves thereon,and
who contracts for such projects with a centrxmr(s)licensed pursuant to his Contractors
License Law.
Ej lamuemprundorSee ,B&PCfordsumaon
caner Da¢
WORKERS COMPENSATION DECLARATION
1 hereby affirm under perWty,of perjury one of the following declarations:
❑]Ism and will maintain aCcnifeme o(Coment to self-insure far WorkcrsCompen-
aeon,an provided far by Section 3700 of the Iabor Code,for the Performance of the
wok for which this permit is issued.
GJ, ere and will maintain Workers COmpenatlee In5Wl..as textured by section
3700 of the labor Cndc,for the performance of the work for which this permit u issued.
My Workers Compensation Insurance carrier and Policy number are: JJ
Carew �.,GNav91T1 polity No.: x-30
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
msisseerim need nolbecomples d'd the permit is fetor hundred dellen(SIM)
m them)
I certify Nat in the performance of the work for which this Permit is issued,I shall not
employ any person in any mannerm as m became subject in the Workers'Compensation
Owe of California.Dam
Applicant
NOTICE TO APPLICAND If,aner making this Certificate of Exemption,you should
become subject in the Workers Cempcout on provisions of the Labor Cade,you mon
.J z forthwith comply with such provisions or this permit shall he detmcd revoked.
z CONSMUC'nON LENDING AGENCY
[--t There by eRrm Nnthere uaed(Sect3097,loading agency for the Perfunnanec of
ai > the work rte which this petted b issued(sec.3097,civ.C.)
aQ leaders Name -
.7 z lessders Add.
U O 1 Call that I have rod thin application and sum that the above information Is
gL t" comm.I acme m comply with all city and county onlinanca and some laws relating to -
0U building eotmmcdon,and hembyaudsmim representatives of Nu city in on..,.the
[27 above-mentioned property for inspection putppma.
F M (We)agree m sae,indemnify and keep harmless the City or Cupcnfno against
fA liabilities,judgmcnm,Cosa and expenses which may in any way women against mid City
U z in consequence of the granting of this permit. /� 4
APPLICANT ERIT
STANOS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date f(%J( /'
SOURC
4aULAT10jS.
n'7In1oi; J
SsgnaturtrX-pp canUConuacmRe-roofs r Dam�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII she applicantor runi buildingeceupana t ttmhandkh Health amaterial
ss aUned M
by the Cupertino Municipal Cade,Chapter 9.112,and the Health and Safety
Code,Section 25532(M?
oyca caro All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant m future Wilding Occupant use equipment If a roof is installed without first obtainingan inspection,I agree to remove
creit
Pp B p q parent lt devise which P
'a'cv eranm air cnntaminao--n//a defines by the any Ana Air Guilty Management all new materials for inspection.
❑Yes (yyrlu
1 hags mad Else haandous memfialsrequisemems under Chepmr6.95ofthc Ca)ifor.
m4Hcxh1,&Safe1y Cade,Secuon 25505,25533 and 25534.1 understand theadthe building
docxnOLcunMntILUCSjmnan4 Nal II u my tespomibility m smury do=upNt of dr
mquire mhmutt tEmortxWm Mcfaccnfwm,oraa'yyypq^ Signature of Applicant Date
>]7 row All roof coverings to be Class'%?."
owneronuthemcd agent Date' g or better
CITY OF CUPERTINO
• 4 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31639015 . 00
DATE ISSUED. . . . . . . : 07/01/2008
RECEIPT # . . . . . . . . . : BS000005310
REFERENCE ID # . . . : 08070006
SITE ADDRESS . . . . . : 20316 NORTHBROOK SQ
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ELIZABETH KOGUT
ADDRESS . . . . . . . . . . : 20316 NORTHBROOK SQ
CITY/STATE/ZIP . . . : CUPERTINO -CA, 95014-0504
RECEIVED FROM . . . . : ALL VALLEY PLUMBING
CONTRACTOR' . . . . . . . : MARY SANDBRINK LIC # 23015
COMPANY ALL VALLEY PLUMBING
ADDRESS . . . . . . . . . . : 3345 SELDON CT
CITY/STATE/ZIP . . . : FREMONT, CA 94539
• TELEPHONE . . . . . . . . : (510) 376-4816
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 750 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 . 48 0 . 00 24 .48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
CITY OF CUPERTINO oko`1 0 L)
WATER HEATER
PERINIMIT APPLICATION FORM
P EkT I NO
ci, 0
oLl-I
Ja C) 7�11one
N'�inle
1 ic--
cuperfin(_, Buffle�zs
J3.6
�
Phone 516
Contact:
F ax-
e-,,i
ILLM, •
Job Descriptioni
A I
Replacement
Bonded —Z ,I-tew Location�T, P'aif, -
Val 00
UaTion:
,,Teen Building Check mist 1; completed and attached to this application
achieved:
�ree-n Building Points aci
CITY OF CUPERTINO
WATER HEATER
C1 OF
OCUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
IPCWHEATR Commercial Water B PCWHEATR
Heater/vent
IBSEISMICOM Seismic Commercial B
p IPRWHEATR Residential Water B PRWHEATR
I HeaterNent
I1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Permit P
I
1TRAVDOC Travel & B
Documentation
j IBUSLIC Business License B
I
•
b Cominunity Development
10300 Torre Avenue
j. Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT# OR
G U7 Q o D CP
� 1 k� f-t'h r'oolC �� . 0
OWNER'S NAME: PHONE # 40)S-25S- 3�
GENERAL CONTRACTOR: FAX#
I am not using any subcontractor .
Signature Date
Please check applicable subcontra rs 4a�nd 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