05070158 CITY OF COPERTINO' yr ' 8''aaewa�.'...,xaf s•� >�' �>'"`` �` '°= ", '
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"' p�RMI'p=.' etCO1V�TRACT®R INFORMATION - I
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uaolrlcnoDRFss:.,µ;':',..;f;, -, - 'JULIO -MEJSX CONSTRUCTION PEam' "°05070158 '
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RRSNAME '14dr, tr,l:^y,,,I . ,s -ii „ ,; .. 1 PERMIT ISSUE DATE
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Wt ,MY f t., T v I ' '361 W VIRLNI4 ST n7/26 2005
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ONE: - SANITARY NO, CONTROL NO.
tit r Ys;tvif+ltr :6t . 408 529-3634 a i
ARCHITECTIgE�NE;°INFER:4 (S4c 5 ;l,. ,- 4 s i V 1. , ,•�
BUILDING PERMIT I
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�[VN-. IECH
ELECT PLUMB M
k `. Iir✓kvm dt�vl , 7 S: t - i, r :)Y • ) ( 0 �I�
uOo } rL4)LICENSEDCONTRACfOR'S DECLARATION I ��vt ' I
.I hereby affirm that I aro limp under pmvWoni.f Chepmr 9(c.mmencin{ Job Description t
�O ithYseclion]IXllp fDivldon3of the Butineoand Pmfeuimts Co ,andmylice=is �� I
^ InnlullImmandefreel RELOCATE 120 ' OF SEWER LATERAL-4 " °
2qz LlcenseClnv - Lk.g ECL
can 'TO ACCOMODATE NEW LATERAL LOCATION
ARCNRECrS DECLARATION
j
p Dam I I ELL t- ABS `.
ARATION E '
t•� Y l �I undentanJ my plans shall herueed u public rtcnrds
pa, Luonmd Pmfeomnala-sl t f G t-•t 1 I u f •r .
gb r -01' v{,OWNER BUIIABR DECLARATIONi,
lilt
Nut I am exempt frum Ne Canveclw's License Law for the
I hemhy}
follnwins maann'(Secti.n/111713 Business and 'f 6.Cade Any Nty tar county
$Pi which elms a' -,itc nYWCt alma imPmro,demulish.or mpmr any structure
itr^ priormiuissuanie:aloerequiretheapplicator.,tachPe,mitmnleasigundstamecnt -
< thnW4licensedpunuaAli.thcp.visioof �law(CWNcr9 Sq. Ft. Floor Area Va
ns dmConuantw*1Lkcluate(lOOO
i6m
rostrum rgwiN Se mon 7000)of DiAsi.0 NC Busi•...and Rofesi.os Code)or
y $ that he'ik exemptthertfmm and Ne tiois for the 1, esempllon.Any violation of '
Seedon 7031.3 by airy applicant forapermit.ubj¢U the appI a ic.civilpenehy.fAPN Number ' Occupancy Type
tom dun Eve M1undsed dollen(5500). 1. i 35706017 . 00'
❑1,as owwr of the property,or my employcu with wage u their sole compenmlon,
will da the work,and the stmcmm is not Intended or offered for spin(Sec.7044,Bwiwns
and Prefeolons Code:The Como mes Llmnse law does not apply m a0 owner of , Required Inspections '
Propenywho WIW orimpmieathereon,andwhodoessuchworkhimselforto.ughhls
ownemployers,provided lhatwchimprnvemmuamnatimmndedmafremdfwsal&lf.
however.Ne puilding or impmvement Is sold within ore year of completion.the owner.
Wilder will love The Wrdcn of proving that Ise did not Wild or Improve for purpose of .
ask.). )', . . 1 '
y}Ms"owner of,dm Property,am exclusively contnming with licensed concert m .. ,.. D
construct the project(Sec.7044;Business and Professions Code:)The Contact Li. 1 ,
cense law docs not apply to in owner of property who Wilda or improves theseon,and,
whocontracts fors hprejectawlN dcoonctor(OlimnsedpunuanlWthe Contractor's -- -
License Law. -
❑temea oder Sec. — B A P C for Of.recon
Date -0
WORKER'S COMPENSATION DECLARATION
r I thereby since under penalty of perjury arc of the following declantiom: I I
I herd and will maintain a Cenlnele of Conon to self-Insure for Worker's Comfo n. I
stion,.o provided for by Section 7100.(IW IaWr Cade.for the per(.rmence of the
work for which this permit is issued. �-� - -
❑1 have and will maintain Worker's Compensation Insurance,In required by Section
37W of the laWi Code.for the performance of the work for which this permit is bound. '
My Worker's Competition Inanrmm enie and Policy number am: -
Cartier. Policy No.l'
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
,(This Whom neetl 1pl Wconplciedirlhe permit is routine hundred dollars;(SIM) 9'
or less).. _
I cenify,that in the performance of the work for which this Permit is bound.I shall not
employ any person in any manunr an an to buvmcmbject to On Workers'Compensation
A N."Califamia.Bna
Applicant A
NOTICE TO ct to On Work E,afterCommeting this Ceninem O Labor
you should
become subject y the Woher'o Compensation or thin provisions of dm m Wr Cnde,you rums
.,0 forthwith comply with such provisions or this Permit shell W deemed mmked.
CONSTRUCTION LENDING AGENCY
[•n I Wmby,affirm that there is a mrstmctinn lending agency l'ordm Perfupom:e.f
tYi
the work for which this permit Is bound(Sec.3097,Civ.C.)
QLender's Name
z I<nder's nddmas
U O I certify that i have reed this application and sum than the aWro information Is
ly ^ corms I a{run m romply with all city and county ordinances and sum is"misting to
building construction,and hereby authorim representatives of this city to enter upon the
F Wsh....mcntioned PMl for Irmpection Pugmses
(We)agree m save,indemnify and keep harmless the City of Cup,tint against
y
rg Ilabllitie,judgmenta,costs and expense which may in any way accrue against mid City
U z in consequence of the 5mnting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date—2/ 2 QS
EGULATIONS.
-7-26-0 Re-roofs
Signature of ApplicanVC.nvacmr Dat
HAZARDOUS MATERIALS DISCLOSURE ,Type Of Roof
Will the applicant or future building.ceupant sem or handle havardous material
dcIII d by dm Cupenina Municipal Code.Chapter 9.12.and the Health and Safely
Section 25532(.0)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 111560
Will the applicant or future building occupant use equipment or deice which If a roof is installed without first obtaining an inspection,I agree to remove
emit lowdnw air conmminanta o kneed by dm Bay Area Air Quality Management all new materials for inspection.
Clavier]
❑Yes W.
Ih&S4fcis. the de,Seces 25M5,2553 and255rincom,undertimmun that if the Gelding
no Hc.0IN6SafwyCode,Sections 23X15.35577 and 25574.1 undemm�d that if the building -
drca not curtcni y hero a upum,the it u my maponalhillly m notify de mcupant of the
.quirt w h must W met p' m issuance of a Cenifmam of Occupancy. e
Signature of Applicant Date
ownww..thonvetl.grot // --7-- -r—u All roof coverings to be Class"B"or better
Community Development
aam
10300 Torn Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT#
C c-- b,go-7 6( S�
OWNER'S NAME: ��EF- PHONE # 08-(ter( - 3o67
GENERAL CONTRACTORade b; � FAX # p ( 0(
I am not using any subcontractors: TLAP-1
Signature Date
Please check applicable subcontractors and complete 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
PlumbingMc JI A j J i u
Roofing
Septic Tank
Sheet Metal
Sheet Rock
0--TTile
Owner/Contractor Signature Date
• CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35706017.00
DATE ISSUED. . . . . . . : 07/26/2005
RECEIPT #. . . . . . . . . : 30510
REFERENCE ID # . . . : 05070158
SITE ADDRESS . . . . . : 10491 SCENIC BLV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MARY REESE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : TERRY BROWN
CONTRACTOR . . . . . . . : JULIO MEJIA LIC # 25252
COMPANY . . . . . . . . . . : JULIO MEJIA CONSTRUCTION
ADDRESS . . . . . . . . . . : 361 W. VIRGINIA ST.
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 529-3634
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 83.16 39.92 0.00 39.92 0.00
BPERMFEE VALUATION 1,000.00 83.16 0.00 83.16 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BPSEWER SEWER SYSTEM 1.00 21.58 0.00 21.58. 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 183.03 0.00 183.03 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 183.03 439
TOTAL RECEIPT 183.03
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
==coocee evvvevveeeeeeveeeeeeveeevvve eveeeevo eeeeveeevoceeeveeeocccvoce==
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
CITY OF CUPERTINO
alo
REPIPE/SEWERS/MAIN SERVICE .
4CUPEkTINO PERMIT APPLICATION FORM 01-56")
APN# Date:
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Building Address: f ^
C� ( C / 06
Owner'sName: Phone #:
AA
Contractor_ _ Phone: icense#:
kju /lJ 24i/ GZS
Contact: Phone: Cupertino Business License #:
��✓ v - asps
Building Permit o:
Bldg ❑ Elect ❑ Plumb yk
Job Description: l2;EL0clr"T'G t 2o' oo St=LAJc-� L y+TE-KA-C- - 4-" fJcg S
La
Residential Commercial ❑
Cost ofProje :
ooh
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 e of Fixtures PLUMBING
BPFDXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWA I Sewage Disposal I PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING