08060059 CITY OF CUPERTINO ,�x"�+
BULLDINO DIVISION PERMIT CONTRACTQR INF4ILMA'CIgN, PtaRtory NO._
Bu1t,1D{[a�gD�R RIEDEL PL TBD — TO BE DETERMINED 08060059
OWNERS NAME: - PERMIT ISSUE DATE
GEORGE & CANDACE IWANYC 06/09/2008
NE: _ _ SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
WOO LICENSED CONTRACTOR'S DECURAT10N Job Description
V 1 hemby affirm Thal 1 an tux used under pmvisimu of Chapter 9(cummeneing p
5qwho Seedon 70(10)afDiviakm Sof the Bard.and Profcssiom Code,and my littnx is REPIPE TO COPPR do REMV & RPLC WTR HETR
i License full �derfect ucL VAN HOOSER ENTERPRISE PD FOR BUS LIC 6/9/8
atm Dam Co..
ARCHITECTS DECLARATION
s
U 1 ustderaand my plast shall the used as public recorda
y y Licensed Professional
OWNER-BUILDER mDECLARATION
E a c I hereby.M.on 1 1. uemps from Ne Cssions Co License Law far do
i.a O fallowing mason. arch t RD LA Business and reprove,
de nm Calc:Any city or county
which requires o tado,re construct,alms,improve,h Permiih,fi repair any Stratum,
ement
pnorbistiumrc4altramto res On,applicantof for the Comarmil Loctome signedstatement
pp < Ihnheincing edpursuion70(¢pmvivisiuo oftheBuazwrinittvclsionsCod¢r9 Sq.F[.Floor Area Valuation
e O that he is exempt
Section 70nd the
basis f r the
the alleged
uand Proon.Any
Code)or $6500
try — that r 7 exempt mertfmm and The baso fits the alleged assumption.Any it Penalty
of
senior 7 than
q am applicant fin(a permit subjects the applicant m a d.0 penny or N Number Occupancy Type
not mom mvn fid hundred dollar(5300} 316 210 50 .MP Y YP
1.Mowrcsofmeprnpmy.mmyemployeeswishdiesathenmkcomp Uon,
winmdmwo&mddmswnnmianotimmndedoranemdmrsWe(sec.ro ,Bu mars Required actions
and Professions Cade:The Curmcmrk License Law does amt apply m e in owner of 9 P
property who Wildsmimpm.thamn,and whodoessuchwaak hiaaelrmthrough his
ownemploycrs,Provided that such improvements are notiounded oro@ml for We.If,
however,the building or improvement is sold within one year of completion,the ewocr.
builder will hale the burden of Proving that he did rot build Or impmve for Purpose of
a
'.as owner of the property am exclusively contracting with licensed commuch rs to
construct dm project(See.7044.Business and Profession Code:)The CoutracmrS L4
came law does t appy m an owns of propcny whit Wilds or improves Thereon,aM.
whecomneuf r hpmjecstwithacontraemr(s)Iicc=dpunuantmtm Cone toes
License taw. -
lam cram � da5ee ,Bk PCforthuscawn
Owner Data �a r7
WORKER COMPENSATION DECLARATION
thereby scan under penalty of perjury o of the following declamsium:
I have end will maintain s Cenifiam of Comcnt w selr-moure for Woheri Co afar.
adon.as pmvid for by Section 3700 of the labor Code,for On performance of the
work for which this permit is issued.
1 have W will maintain Worker's Compemadan Insurance,as required by Scalar
3700a(the Later Code,fm the performance ofthe work for which this permit is issued. '
My Workers Cmnper adon Insurance carrier and Policy number art:
Carfies, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rr41n .
of Wcmnpmval tame Permit lsfaronc hundred danaa(SIM)
or lcons)
1 certify Narce of me work for which this Proms u issued.1 shall not
employ anmanrcrsemthbecam Subject res the Workm'Compensation
Laws of CApplicanaNO ICEr:IL afmr matin u Certifimm of Eacmption,you should
become Safteri Cumpcmation provisions of the Labor Code,you mets.z faMwith h pmvisiom or this permit shall W decreed revakcd.
'Z O CONSTRUCTION LENDING AGENCY
r
(-r I hcrthy cTrm mar mart is sued(Suninn lending agency lbs me performance of
C'IM the dark for which this permit It issued(Sec.7097,Cl,.C.)
ty Q Lenders Name
.7. z Landers Addrrss
U Q I certify than 1 have mad Ws application aM sum Na the above information is
{I. P cones 1 agree to comply with all city and county ordinances and sum laws relating to
pU Wilding conss��rresion,and hereby authmie mpreacnulives of this city m enter upon the
r W aWve-menudnkd pmpcny for inspection purposes
gy (hep)ag'rm to ave,indemnify and keep hamlets the City of Cuprnian agaimt
fA liabilitq udg cots,coast and eapcmes which may in any way eccme againssaid City
U,'� in conseq noifolItha Lran L of this permt
APPLICA UNDER NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /V
SOUR GULATIO /'
(� Re-roofs
SignaAppliaricanvactor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy t applicant or future building mcupantssore a handle Heardomdmaterial
Welly
m denned by 25 Cupertino Municipal Code.Chapter,9.17.and the Health and Wcsy
Code,S yes 13333(+)7
❑rue prro All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mbsm Wilding nit spam ase equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
� he7stalmm air canuminanis tiefincd by the Bay Area Air Quality Management all new materials for inspection.
❑Yue [j Nu
Iha mehvardousmamdabrtquirtmcntsunskrCWpmrQ93oflheGlifor-
nulicalth s mycotic.sewmts7ssas.ss333andsss34.1aweraawmaifd,ebu;aing
dam wt tIY have a l tut it u my mspomihilihY m notirY Ile attupans of dre
rtyulrtm hichmusr etpdormissuarcco(aCastiOcamofOccu Signature of Applicant Date
All roof coverings to be Class v
Ownc uthori sd agent Dam- g assor better
CITY OF CUPERTINO
• 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN , . . . . . . . . : 31621060 . 00
DATE ISSUED. . . . . . . : 06/09/2008
RECEIPT # . . . . . . . . . : BS000005039
REFERENCE ID # . . . : 08060059
SITE ADDRESS . . . . . : 10143 RIEDEL PL
SUBDIVISION . . . .. . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GEORGE & CANDACE IWANYC
ADDRESS 10143 RIEDEL PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : GEORGE M IWANYC
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BPWATER UNIT 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1BSEISMICR VALUATION 6, 500 .00 ' . 0.. 70 0 . 00 0 . 70 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 147 . 55 0 . 00 147 . 55 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 147 . 55 AMEX
---------------
TOTAL RECEIPT 147 . 55
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
D, CITY OF CUPERTINO
• REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 a O0 , c7 () Date:
5 J�q(o8
Building Address:
�Ol'-l3 2�edat P1gGe ' � �vto GJ� a5ol�(
Owner's Name: Phone#:
C C�-lc�Y,� 1i2�- a-o91
Contractor: Phone#: Cyd 53(x- osso
Fax#: u/t4,
Contact: Phone#: ('09 14 2,. B6So
Fax#:
Contractor License#:
Cupertino Business License#:
Job Description:
Ramie2 1:� c�wMx s `�l"r Afl (�e �,at 4
• waY.r 1nan�.-,r
Residential Commercial ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable,Include in plan set& the sheet index.
Quantity Fee ID Fee Description Fee Permit Type
Grou
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
IBPREPIPE Commercial re-pipe per fixture P ICPRP
I PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
• 1BSEISMICR Seismic Residential p
IPRSEWER Residentialbuilding P 1RPS5
sewer/senile sewer
31P CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
C1 0
• CUPER,TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1 PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
I PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
( IBPFIXTURE Plumbing Fixture P
IPGASRES Residential Gas Piping System P
1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
• / IPPERMITFEE Plumbing Permit Fee Issuance P
1 PLMBLNCK Plumbing Plan Check P
1 PLMBINSP Other Plumbing/gas Insp. P
/ 1TRAVDOC Travel & Documentation Fee B
I 1 BUSLIC Business License B
•
Community Development
s 10300 Torre Avenue
Rx. Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WUPEkTINO
Building Department
JOB ADDRESS: . PERMIT #
IONS d2;rbc,( Pl 0do" Z. S y
OWNER'S NAME: a T , PHONE #
GENERAL CONTRACTOR: ,oG K c t(a,u� FAX #
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
Sheqt Rock
Til
Owner/Contractor Signature Date