04090032 CITY OF CUPERTINO
BUILDING DlvlsiON •PERMIT
BUILDING ADDRESS: . - PERMIT N0.04090032
107
OWNER'S NAME: PERMITL'SUEDATE
MAXINE & JEFF BECKER
E:
SANITARY NO. CONTROL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
cl o o LICENSED CONTRACTOR'S DECLARATION
u� 1 hemby affirm that 1 as littnsed under provisions of Chepmr 9(commencing Job Descrlptl n
?Lqwith Sation'").(Division 3 of the Busineesand Professions Coda,and my Hconac is
jy Nfall.mu CI&and e0en' REPIPE OCT Z9 ZUU4
g Z License Class Lk.a
n t- Date Contractor
ARCHITECTS DECLARATION
�i 1 understand my plans shall he used as public records
BUILDING
�Q� LiccnscO Pmfasaionel
g OWNER-BUILDER DEH.CmHaION
F. I hereby affirm that I em exempt from Ne Cssions o License Law for the
F.e O following mason.permit
t II13 sa B.chat. and improve,
de io demolish,
Code:Any oily Ors unty
ante
ce$ whim requires a permit m ennnruct.eltec impmw,.dcmolish,nr repair any awnure
FZi prior hs its issuance.also requires the applicant for such permit to file a signed statement
e that he is licensed pursuant in the prevision ofHmContractors License Law(Chapter Y Sq.Ft.Floor Area Valuation
as (cammeneing with Section 7000)Of Division 3.f do Bantu.and Professions Cssdc).r
.. Nat he is asempt therefroa and the basis for Has alleged exemp0on.Any viOlmion of
Section 7031.5 by any applicant for a permit subjects the applicant)0 a civil penalty of 3W`1117 1diber00 Occupancy Type
not more than rive hundred dollars(5500).
❑I,as owner of the property,or my employees with wages u their sole comPenuthm,
will do the work,and Ne structure isnot intended or offered for sale(Sec.7094,Business
and Professions Cade:The Contractor's License Law docs not apply m an owner of Required Inspections
pmpeny who builds orimproves daeon,and who doessuchworkhimself orthrough his
own employers,provided Nat such improvemanu arc notimended aro@red formic.IL
however,the building or improvement s said within one year of completion.Has Owner.
Wilder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
1.as owner of the property,am exclusively contracting will licensed contractors in
c struts the project(Sec.7W.Business old Protean...Code)The Contractor's Li.
sena Law docs not apply to an owner of property who Wilds or improves demon,ad,
who contracts for such projects with a crnlractnKs)licensed pumuenl to the Conlfamlari
Wanse Law.
❑larnmemcpttemHOSea .Bk PCmrmismson
woe .�/f/ - ^ Data v�t-
WOPIJCERS COMPENSATION I%LARATION
1 y affirm under penalty of perjury one of NiTdl
bereblowing declensions:
_ I have and will certain aCenifteme ofConsem to self-insumfor Worker's Crmpen-
action,as provided for by Section 37M of this labor Code.for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's COmPemation Imurutce,as required by Section
3700 of Ne Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complemd if the permitisfnranc hundred dollars(SIM)
or Ices.)
1 certify Nat in the performance of tha work for which this permit is issued,l shall not
employ any person in any manner so az to become subject in the Worker%Compensation
Laws of California.Dare -
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m Ne Worker's ConcPsensminn provisions of Ne Labor Cnde,you must
.`O roMwim comply with Such pmvis.ns m His permit shall be demand revoked.
,z",y CONSTRUCTION LENDING AGENCY
[—t I hereby affirm mal thea is aconmruction lending apacy for the performance of
tY 7 the work fur which this permit is issued(Sec.3097,Civ.C.) ..
QLanders Namc
aC14 z Lenders Address
U Q 1 anlfy that I have read this application and state Had the be.informed..is
H correct.I agree to comply with ail city and county ordinances and tare laws relating to -
pU building construction.and hereby minuiro teprexmatives of this city 10 enter upon the
W above-mentioned property for inspection purposes.
LF^^gy
(WH agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgment.casts and expenses which may in any way same ageinalsaid City
in of the granting of ts pornalt.
U!� APPLICANTOUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date "
SOURC�F.gF�LATIONS. /
%//! `— ),,,�.-�"— g-rro'�' Re-roofs
ytsnuture of ApplicanUContraetor
HAZARDOUS MATERIALS DISCLOSUREeType of Roof
Will the Spplinmor future building acupantsmre mhandlc arad.ustcmaWoal
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Code.section 25533(0)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes -QNu
Will me applicant or future building accupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hmardnm air contaminants u Fined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea No
I have mad the incautious materials requirements under Chapter 6.95 of the Califor-
at.Health&Safety Code,Sections 35505,15533 and 3553x.l umussuond Had it the Wilting
does not currently haw a Hamra,that it is my respoaibilisy 10 notify me resonant Of the
myuircisi unW met poor to. ofs CpniFicatc of occur��y. ignature of Applicant Date
own euthorizcJagcnt ��— All roof coverings to be Class"B"or better
CITY OF CUPERTINO
2 of 2 PERMIT RECEIPT OPERATOR: suem
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot: -
APN . . . . . . . . : 34217046.00
DATE ISSUED. . . . . . . : 09/08/2004
RECEIPT #. . . . . . . . . : 26959
REFERENCE ID # . . . : 04090032
SITE ADDRESS . . . . . : 10723 SANTA LUCIA RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : MAXINE & JEFF BECKER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3939
RECEIVED FROM . . . . : MAXINE BECKER
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP" . . . ..
TELEPHONE . . . . . . . . :
ID UNIT QUANTITY AMOUNT PD-TO=DT THIS REC NEW BAL
_____ _____________ __________ __________ ___________ __________ __________
BPERMFEE VALUATION 1,300.00 83.16 0.00 83.16 0.00
BPREPIPE NO OF FIXTURE 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 130.53 0.00 130.53 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ _______________-__
OTHER 214.55 VISA
TOTAL RECEIPT 214.55
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
0
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
OF
. CUPERTINO PERMIT APPLICATION FORM
APN#
Building Address:
a3 0. 4U010, 96f
Owner's Name Phone#:
ou ire e��- y2-3f014
Contractor: License#:
14-" +- Phtm hir<. 3 y? y
Contact: r ft&L I4&PL Cupertino Business License #:
Building Permit Info: 6
Bldg ❑ Elect ❑ Plumb-93�
Job Description:
Residential Er4, Commercial ❑
Cost of Pro'ect: .:
•
Qty
A cab Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING T .
BPREPIPE Repipe of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•