06050224 CITY OF CUPERTINO +
BUILDING DIVISION PERMIT CONTRACTOR INk'URMATION
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BUILDING ADDRESS: GREENFIELD PLUMBING PERMIT No.06050224
22676 ROYAL OAK WY
OWNER'S NAME: PERMIT ISSUE DATE
PWU 3513 MADRID DR 006
E:
SANTfARY NO. CONTROL NO.
(408) 921-8980
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG EIJ?C[ PLUMB MECH
:oo LICENSED CONTRACTOR'S DECLARATION
C 1 hereby aff re that 1 am licensed under provisions of cmpkr 9(commencing Description
eito with Section7tgs11)of DiAAan3ofthc Bu4. udProfcssfum Cade.andmylkenses
in roll face and effecs ? �+„ REPIPE OPPER INCLUDE FIXTURES FO
i q Liecnse❑ass IY.a ��_ '�
Dak��`rsFmLfo
Dain SFDWL
If� I `ictsumd en �e RCHITFCr'S DECLARATION ��N �_ 2006
w U I undcrsanJ my pWu shall W used u public mcnrds
•a
at; um.d Proremoml
ot 5 OWNER-BUILDER DE RATION �aa aa'�®���
f I hmeby alum rut I ins exempt f the Conuutor's License Law far the pUp
CC fallowing mann.(Section ZD31.5,B.Pi f antl Prorusinm Code:Any city m county
<m ff which rtquires a Permit to construct.alk,,improve,demolish,or repair any structure
prior In is issuance also require the applicant for such pamil an Gk a signed,mccem
<
that he is pursuant licensed pursuano the provisions of Me Consumer's license law(Chapkr9 Sq.Ft.Floor Area Valuatigia000
[ O (commencing with Section 7000)M Division 3 of the Business and Professions Code)at
y that he I,..map,therefrom and the bass for the alleged exemption.Any violation of
Section 7031.5 by any applicator for a permit subjects the applicant to a civil penalty,of N Nu30 .
mber Occupancy Type
not mom than fin hundmd dollars(M). 3 4 2 3 3 0 . 00
❑Lav owner o Me and Instanter..is maimeyees with caoffered Po Nov m.campers inns
will do fessm.and,:The Core i¢nces License
Law does not apply 7044,Business
of
and errywho bis code:The Cenmctors License uw dem am apply lf at owner or Requited Inspections
property who builds i i d thatuch Improve who doessuhende himself e,roulade his
owneer.%
Wilding
pr svemimprovemensarenot year
o(cmonead roulade.lf.
build.,,.Ne Wildindorimpro novi.,soldwidid one ilderrimproedfrNeowner-
.1.Lr will have dk border of proving Nat he did mat Wild or improve for Puryose Of
saki.
❑1,v mane,of Ne property,am exclusively contracting with licensed comrumrs to
commoner the proper(See 7014.Business and Profusions Code:)The Cone amees Li
cane Law mos mat apply w an an,Or protan who Wilds or improv thereon,rd
who contracts for such Projects with a conuactor(s)licensed pursuant m Me Contractor's
License law.
❑I am ua.pt undm Sec. .B @ P C fm this ream
Owner Deck
oWORKERS COMPENSATION DECLARATION
thereby eby alRrm under penalty of perjury re oof the following declarations:
1haveandwillmaintainaCe rimmof Comenttemtf-imumfmWorker'sCompen-
Oman,as provided fan by Section 3700 of the labor COMO.fm the performance of the
wank for which this permit is issued.
❑I have and will maintain Worsens Compensation Insurance,as required by Section
3700 of the labor Cade.far the peRormance of f wall,for which this permit is ismal.
My Worker's Compensation We.units and Policy numhcr art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
flits section send not k eomplekd true permit 4 fanom hundred dollars($100)
or less)
1 ceoi(Y dot in Me perfoonsme of the wort for which Nis Permit s Wood.1 shall not
employ any peen.in any manner ate been a ubjen a the Wort Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICAf . :ing this Cenifiuk of Ekmplion,you Mould
became mbjca to rikcu Compensation pmvisiom of the labor Code,you mus
.J z forthwith comply sun -once prevsions err Ns omnis shall W deemed maker.
z O CONSTRUCTION LENDING AGENCY
(-+ I hereby aRren that there is a conshction lending agency for Me perforrommof
cL> the work rur which this permit is issued(Sec.3M.Ch,c.)
Qlender's Namc
z Lender's Address
V C I certify that 1 have mad this application and more that the aWve information is
IL H gamed.l agree to comply with all city and county ordinances and state laws relating to
OU building construction,and hereby authorim representatives Or this city to enter upon the
above-mentioned
gment.cost for inspadon purpowhich ms.
(Wo)agree to save,indemnify and keep torturous the City Of Ci penim against
Uh inconsociu m,ofth,gran and of this pe whirr may in any way aggro againstsaid City
V z A PLICA rcerflWgrantingof this pe
r-. APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION
�/( u ��1 Re-roofs
Signature of Apphay rnuacTor Deck
rHA, BOGUS MATERIALS DISCLOSURE Type of Roof
Wi11 the applicant a'
far.building oecupamsrom or handle hactrdons maknal
u defined by rte Catenate Municipal Code.Chapter 9.11,and Me Health and Safety
Code Section 255310)? All roofs shall be inspected prior to any roofing material being installed.
C]Yet pio
41 Will the applieent or future Wilding eccupam use equipment or dcvicm which If a roof is installed without first obtaining an inspection,I agree to remove
emit havLnu all contaminants u dcOrcd by the Bay Am.Air Cushy Management all new materials for inspection.
Distrin?
Dy.
Ihave road Me C.dc,Srddtsmatm5.255311 immenuunder GhaPkrh95of c Wilding �J.� /
ns Healthomedy have
neutiauorit my ad125534. rmMthmifthe Wilding J _ �iC/l.
drat net currenrY have a tenant Jw it s my mato m edify IW orator of Ute
mgairemcnuwhichmustWmeI ata enifim praNpatky. Signature ofAp cant Date
Owncro ..thomada Dore All roof coverings to be Class"B"or better
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34232130 . 00
DATE ISSUED. . . . . . . : 05/25/2006
RECEIPT # • • • • • . . . . : 34566
REFERENCE ID # . . . : 06050224
SITE ADDRESS . . . . . : 22676 ROYAL OAK WY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PWU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : GREENFIELD PLUMBING
CONTRACTOR . . . . . . . : TRAN, TOM LIC # 20711
COMPANY . . . . . . . . . . : GREENFIELD PLUMBING
ADDRESS . . . . . . . . . . : 3513 MADRID DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95132
TELEPHONE . . . . . . . . : (408) 921-8980
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- --------- ------------- -------- -- ---------- ---------- ---------- ----------
BPREPIPE NO OF FIXTURE 9 . 00 81 . 00 0 . 00 81 . 00 0 . 00 .
BPWSVCS WATER SERVICE 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 128 . 37 0 . 00 128 . 37 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- -- -------------- ------------ --- ---------------
CHECK 128 . 37 1680
TOTAL RECEIPT 128 . 37
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
•
N,
/ ;a* Community Development
/ 10300 Torre Avenue
F � Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
4§UPERTINO
Building Department
JOB ADDRESS: PERMIT #
z 6 l
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: I FAW
I am not using any subcontractors:
gna a Date
Please check applicable subcontractors and om lete 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 ontractor tgnature Date
CITY OF CUPERTINO
I REPIPE/SEIvVERS/MAIN SERVICE
CITY OF
• CUPERTINO PERMIT APPLICATION FORM
APN# '5D Date: _
Building Address:
Owner's Name: Phone#:
Contractor: Phone: License#:
F, v Z Z
Contact: Pone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb -E�,_
Job Description:
Residential Commercial ❑ F-
Cost of Project: nDO✓
• C/
Qty. if
Applicable 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 eofFixtures PLUMBING
BPFIXTURE Pbig. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING