04060024 CITY OF CUPERTINO =p m «t,
BUILDING DIVISION PERMIT Cb1VTRACTUR�TNT('()TtMATTUN"
.t".
OUILDING ADDRESS: BAY AREA REPIPES - 111MI1ND04 0 60 024
OWNER'S NAME: PERMITL6UBDAM
Aft SHIRLY YANG 1861 ORANGE GROVE T)P
lorC' SANITARY N0. CONTROL N0.
(408) 371-5763
ARCHITBCTy GINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
3M a 0 0
0o LICENSED CONTRACTOR'S DECLARATION o
wi F I by affUm that I am II¢nud under provisions of Chapter 9(mrmomo ng Job Description
K4 wlNSat n]IXMgofDivialon3ofNcBuun�ru/a1�,Yro(csdnmCodc,endmyliccuc6 �e
'g= �i I 0 ass effect. 3G Lk.N fi'0/93G REPIPE ENTIRE HOUSE . Fl,�g���®
Date — Cugmnl� lgrrE al
ee ARCHITECTS DEC I
%i U h understand my plana shall W used as public MOON, �Pe�jos JUN 7 — 2004
1 G G Lwcnxd Profcon Maj
i�,3 OWNER"BUILDER DECLARATION
F I hereby affirm that I am txempt form the Courtroom's License Law for the BUILDING
>O O fallowing Mason.(Section 7031.5,Business and Professions Code:My city or county
z B� which acquires a permit to construct,alwt improve,demolish m repair any structure
poor poor ar its issuance,also requires the applicant for such permit to file a signed statement
Nal he is licensed pungent to the Provisions of NC Controller's Umore❑w(Chapter 9 Sq. Ft, Floor Area Valuation
$ (cummendngwith Section7")Of Division3of NCBusim 4nd Pro(essinns CO )ter
Nat he is eumpt therefoo.and dw bash for the alleged exmpuon.Any violation of
Section 7031.5 by Ory applicant for a permit subjects the Applicant to a civil penalty of 3 61�N4'Qillltber0 0
net mele than Rae handled dollars(M). Occupancy Type
❑I.uownaof(Mpmpcny,ormyemployeuwiOwaguu1 ir3DlecompenUdon,
will det the work and the'wcmM is not intended or offered!mine(Sec.70,14.Buuru
and Prefessiau Code:The COgacMfl LI«lex Law does not apply on an Owner or Required Inspections
propertywhO Wildaarimproves dimmer,and who does such work himself orthrough his
own employees,provided that such impmmo ents art notinaMed or offered forsale.If.
however,the building or hnpmvament is sold within one year of completion.the owners
builder will have the burden of proving that he did not Wild or improve for purpose of
tits.).
❑1.as owner of the property,am ucluivehy contracting with licensed contractors he
contest the project(Sec.704,Business and Pmfu hands C(de:)The Conwuar's Li"
cense law does not apply to an owner of property who Wilda or Improve,thewon,and.
who summers for such projects with a eonlnctor(p Ilcenxd pursuant in the Contractor.
License Law.
❑lam exempt under sec. ,B h PC for this rtawa
Owner Dat
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a CoNfiate of consent o self-insure for Workeh Compee.
on,u provided for by Section 3700 of he Labaf Code.for the perfamenro of the
.it for which this permit Is issued.
O 1 have and will maintain Workefs Compression cion Insurance,as required by Sccfion
37W of the Labor Cools,
for Ne performance of the work for which this permit is issued. �
y`er:rk C K },fo;, Ona conmer and
000lliicy another r;
CERTIFICATE OFF.XEMPW0NFR O,BRZ11dW KERs
COMPENSATION INSURANCE
(This section aed not W completed If the Permit is mronchundre4 dellen(glg))
ler leu)
I certify Nat in the Perfermaae of Ne work for which this Permit is issued.1 mall not
employ any person In any mannerm as M WUme subject to dw Workcts Compensation
U,vfbf California.Dare
Applicant
NOTICE TO APPLICANT:If.efler making this Cenificate of Exemption,you should
became'Object M Ne Wmkm3 Compensation provisions of dw Labor Code,you mug
0Z forthwith comply with such provisions or this pmorkshail W deemed ovulate.
z CONSTRUCTION LENDING AGENCY
N
F+ h hereby ich thi Net Nen iasued( m,3N7,,Ch. agency for Ne PcrfurmenU of
6Y, the work for which Nh permit is issued(Sec,J097,Civ.C.)
GQ Lender's Name
.� Lenders Address
V Q I Unify that I have mad this application and sale that Ne above information is
is,(~ cornea 1 agree to comply with all city ted county ordinances and saw laws relating t0
QC) building construction,and hereby salmon,ToPreseOathm of this city to enter upon One
aWvcmejudgm Property roan inspection which
may
ti y (We)Agra to save,indemnify and keep harmless the City of Cupertino against
fq in consequence
eapenxsmit. may In any way seems against ssie City
U z inconsequence of the gra ng of this Permit.
^ S APPLICANTND S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
(o -O -so 5a Re-roofs
Signeof Applimn 0ammMr Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding nesup al Rom or handle harudous mawoH
a defined by the CuMnim Municipal Code,Chapter 9.12,and the Health and Safety
ndt,saYonas32(a)7 ssff����...��,' All roofs shall be inspected prior to any roofing material being installed.
❑Yes vgk(o
Will the applicant or future Wilding occupant use equipment or dcvicas which If a roof is installed without first obtaining an inspection,I agree to remove
W,arenu air Ionamin rs ss dcfineJ by IW Bay Arca Air Quality Managcmcm
„ all new materia for i s ection.
❑Yes
1 have real the haaardaus materiels requirements under Chapter 6.95 of the Califon
.is Heal O A Safety code,Sections 25505,25533 end 25534.1 understand thu if Ne Wilding
does not c t ant.llu k u my nspouibihity w notify the occupant of the
require m tyt. r toismance Ora CcNfieacof Occupanry.
---
I
rte; ._�,L c y Signature of Applicant Date
ownerQ au io raze ae ac Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36215001.00
DATE ISSUED. . . . . . . : 06/02/2004
RECEIPT #. . . . . . . . . : 25724
REFERENCE ID # . . . : 04060024
SITE ADDRESS . . . . . : 1044 NOVEMBER DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SHIRLY YANG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4123
RECEIVED FROM . . . . : BAY AREA REPIPES
CONTRACTOR . . . . . . . : JOHN SWANSON LIC # 23773
COMPANY . . . . . . . . . . : BAY AREA REPIPES
ADDRESS . . . . . . . . . . : 1861 ORANGE GROVE DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95124.
TELEPHONE . . . . . . . . : (408) 371-5763
%E
ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BPERMFEE VALUATION 4, 000.00 97.00 0.00 97.00 0.00
BPREPIPE NO OF FIXTURE 1.00 8 .33 0.00 8.33 0.00
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 140.85 0.00 140.85 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ -------__--__--___
CHECK 140.85 2171
TOTAL RECEIPT 140.85
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507. FINAL PLUMBING