06080163 CITY OF CUPERTINO ^. a
BUILDING DIVISION PERMIT .. ONTRACTOI2INk'ORMrkTION -.
BUILDING ADDRESS: VANDONZEL CONSTRUCTION PmMITND'06080163
10541 RANDY LA
OWNER'S NAME: PERMIT ISSUE DATE
WALTER PEREZ _ 1170 CLARK ST n8/i8/9.006
E, SANITARY NO. CONTROL NO.
(408) 295-9045
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION Job DescriptionuC 1 hereby arm that 1 am licensed under transient,of Chapter 9(commencing
�z union
with IWO)efDivision 3 ofdte Business and Professions Code,and lien.is
�N inml)frtnee a=d e TEMPORARY POWER POLE
q u.enae assn tees a
^p D01e GOnD L
• J shalthCTS DECLARA da L_Aw�
i s I undcrsunJ mY Plans shall he uteri an public recorJt,
tau /J
.ups LiscnuJ Pndasional ���j�` A
OWNER-BUILDER DECLARATION Y/[\�/
E I hereby affirm that 1 am exempt from the Contmcters License Law For the ±—Y
.p 0 following moron.(Section 7131.5,Business and Professions Code:Any city or county V
1$9 which requires a permit to construct.Sher.improve,demolish,or repair any suueure 300
prior to its issuance,also requires the applkant for such remit o file a signed statemem
that he is licensed pursuant to tha provisions of ds,Contmcturf limns,Law(Chapter 9 Sq.Ft.Floor Area Valuation
[�0 (commencing with Section 710r))of Division 3 of We Business and Professions Cede)or
that he s exempt 1ltemfmm and the bass for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a Permit subjecu We applicant to a civil pcmlly of APRr Occupancy Type
not mom Nan five l uWmd dollars(5500).
❑1,as owner of the Property,or my employees with wages as their sole comperassdon,
will do the work,and thn couctum is not intended car offered for sus(Sec.70".Business Required Inspections
and Professions Code:The Contrsemes License Law does not apply m an owner of q p
pmpe y who builds or improm thereon,and whodossuch work hireselforthrough his
Own employees.provided that such impmwments are not intended oroffemd for sale.ff,
however.the building or improvement is sold within one yexr afcompledon,the owner,
builder will have the burden of proving drat he did ret build or improve for purpose of
Sale.).
❑1,as owner of de property am eaclusivcly...basting wish Bcensed contrxmrs to
coseuct the projttt(Sec.7016,Business and Professions Cade:)The Co drac ori Li.
cense Law dem Mt apply m an owner of Property who builds or uninom thereon.and
who contracts for such pmjem with a merness (s)licersud personal or the Coneraccoes
License law.
❑Iamexemptunder See .B&PCfar Wsrcnon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hareby anmn under Penalty of perjury one of the fallowing declarations:
I haK and will ma rtuin a Certificate of Content no self-imam for Worker.Compen-
on,as pmvidcd for by Seem.3700 of the Labor Code,for We perfmontrce of the
wah far which this permit is issued.
1 have aha will maintain Wokeh Compensation Insurance,as Oxim.d by Semon
7 of the Lobar Code,for the Nd...or the work,fee which thispermit is issued.
My Workers pem1ati�en hasuvrua mnio end Policy number am:
Canter:_ "L)� n """'Poing No.: Iva
CERTIFlCATEOFEXEMPTIONFROMVOILKERSF
F
COMPENSATION INSURANCE
(fhs.e.need not be compleed Jshe permit 4Ionone hundred doRa x(5100)
or less.)
I certify that in We performance of the wart far which this Permit IS issued.I shall not
renin.;any person in any monmru as or become subject to the Workers'Comperuatien
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after mating this Ccoifcate of Exemption,you should
become subject no the Workers Compcnsadon previsions of she Inbar Code.you most
.J,Z, forthwith rovn or comply wit such pisioWs permit shall Mem
deed revalued.
z O CONSTRUCTION LENDING AGENCY
[+ l hemby aRrm Uva Were iso cmntnexim.lending agency or We NxImmort
!Yi the work for which dos permit s issued(Sec.3097,Civ.C.)
C Q Lenders Name
,a z Lenders Address
U Q 1 certify that I have mad this application aha sum thal We above information s
U, comm I agree to comply with all city and county ordinances and sou laws relating to
� building construction,and hereby authorise repreeenutives Of this City to Cowruponthe
Uahovcmentioned property for inspr.tion pu a.
py (we)acme to ate.indent try and It ICU c City of Cupertino against
tq liabilitiesjudgme d r ay in Tway accrue aga
rimtsaid City
U z ins nee W this pc `� /
^ A LIC 5 AN IL PLY WITH ALL NON-POINT Issued by: Date U b
50 R 0
Re-roofs 2--
Signature of Applian✓Contractm Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcuro nt3tom or handle hamNous material
an defined by the Cupertino Municipal Code.Chapter 9.12,and the Hcalsh and safely
code.Se 2ss3z(a)7
ecy. � All roofs shall be inspected prior to any roofing material being installed.
Ys
Will the applicant or future building occupant use equipment or devices which If arceaftalled without first m an inspection,I agree to remove
ha
.mit raknes air cunumimmus as defmcd by the Bay Area Air Quality Management all ew mat 'al O IOn.
Dana?
[3 yes bNu
I haao read the narod material irc no r LTapterti.95crf thc Califon /rte
nix Sof ti 75505, 3 25534 unukrsund thatifde Wilding (J]^
d not c Y ,doaits nes nsi 'rty u noifY she ocmput of the
mqu n mOil 6 rt San a Ccmrca fas.,>sn^y. Signature of Applicant Date
Owner or aothon.c agent / D,m- All roof coverings to be Class "B"or better
b, Community Development
v 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPERTINO
Building Department
JOB ADDRESS:
PERMIT O
OWNER'S NAME: U L vL ONE #
GENERAL CONTRACTOR: #
I am not using any subcontractors: _
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31602054 . 00
DATE ISSUED. . . . . . . : 08/18/2006
RECEIPT # . . . . . . . . . : 35688
REFERENCE ID # . . . : 06080163
SITE ADDRESS . . . : 10541 RANDY LA
SUBDIVISION
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : WALTER PEREZ
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : VANDONEZEL CONST.
CONTRACTOR . . . . . . . : PAUL VANDONZEL LIC # 28014
COMPANY . . . . . . . . . . : VANDONZEL CONSTRUCTION
ADDRESS . . . . . . . . . . : 1170 CLARK ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 295-9045 .
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -- - ---------- ------- --- ---------- ---------- ---------- ----------
BTEMP FLAT RATE 1 . 00 62 . 10 0 . 00 62 . 10 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ------ ---- ----------
TOTAL PERMIT 100 . 47 0 . 00 100 . 47 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
---- --- - - -------- ------ - ----- ------------------
CHECK 100 . 47 8146
TOTAL RECEIPT 100 . 47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 304 ROUGH ELECTRICAL
•
CITY OF CUPERTINO ptoo�o�f�3
Su___ TEMP POWER
CITY OF
•CUPEkTINO PERMIT APPLICATION FORM
APN # D
Builth, Address: \ '
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Owner's Name: Phone #:
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Contractor: 11 Phone: L/OFf S License #: _
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Contt: q Phone: Cupertino Business License#:
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Building Permit Info:
Elect
Job Description:
Residential �5. Commercial ❑
Cost of Project- 1i
•
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BTEMP Tem orary Power ELECTRICAL
I EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING