06090145 CITY 0,17 CUPERTINO ,y
BUILDING DIVISIONpERMIT CONTRAC�`TOWINR
FOMATIdN
BUILDING ADDRESS: PERMIT N0.06090145
6033 SHADYGROVE DR
OWNER'S NAME: PERMIT ISSUE DAIS
CHARLES ROSENBERG & WENDY AN 09/19/2006
NE: SANITARY NO. CONTROL NO.
ARCWTECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�QO LICENSED CONTRACTOR'S DECLARATION - JOb Description
1 hmcby.aflimi that I w licensed under pmvivms of Chapter 9(commencing
nrulllto=and if«°naony°rat B .spar °nc°°'shot myli" u NEW SEWER LINE TO GARAGE FOR WASHER & DRYER
y 1 z License Class Lie.g
F o
Date Comracmr
pp� ARCHITECTS DECLARATION
1 W I understand my plans shall W used as public records
G Licensed Professional
5 OWNER-BUILDER DECLARATION
E 1 hereby affirm dim I am exempt from the ConlracmYs License Law for the
OC following maw..(Sada.9011.5,Business and Poidam s Code:Any ch,at ceonly
C
o29 which¢Quirts•permit to consumer,aIle.improve,demolish.ler repair any met.. $2000
°I< prior In its issname,also rill the applieam for such Permit o rile a signed stsmmem
ss that he is liamand pursuant to tW Provisions of tW Contractor's Liecnse Law(Chapter 9 Sq.Ft. Floor Area all3atlon
uFC (commencing with Section 7000)of Division 3 of the Business and professions Code)or
y 5— that W I,.tempt thelefrom and the basis for We alleged aemption.Any violate.of
Section 7031.5 by any applicant for a permit subjects the applkant in a civil penalty of r Occupancy Type
not mart than five buwmd dollars
0 1,has owner of the property,or my employees with wages as their soic compensation.
will do the work,and destruct..Is not intended or offered for sa@(Sac.7044,Business
and Profession Code The CardocmYs Liarse Law does not apply an.owlet of _ Required Inspections
property who Wilds or improves tenon.and who does such were himself or through his
con employees,provided that such improvements are not selected aro@ted forsale-If,
hmvevcr.Ne Wilding or improvement is held within one year of compkton,the owncr-
Wilder will have the WNan of Finding that he did rias build or improve for purpose of
V1.[ 1.as more,of this property,am"elusively contacting with ticused conuamors to
comma tk project(sec.7044.Business and Professions Cade:)The Conuacmrs V.
cense law does not apply m apo owner of propcny,who Wilds or improves therrnn,and.
who contracts for such Projects wish a contractor(s)licensed Pursuant to the,customers
License law.
0 l am acmp,under See ,B&P C far this on
Owner Data ttsir-b
WORKER'S CO. TION DECLARATION
1 hereby affirm under penalty of perjury ore of the following declaration: - w
Iha,e and will maintain aCeniGate of Content to self-msum fa Worker's Coolant.
sasion,as provided for by Seaima 3700 of the labor Cade,for tW performance of the
work for which this permit is issued.
0 1 have and will maintain wliftes Compensation lnwrance,as required by Senior
37W of the Label Cade,for the Performance of the work fur which this permit is issued '
My Worker's Compensation Inursece caria and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(noticed.act rmtbecompked if the permit u formic hundred dollar(3100)
.chess.) D
1 certify thin in the Perform... de work for which this permit is rs'Com stall not
Lawsemployo any Perhen in coy manarhe b b come subject u de Woscri Compensation h
Laws of Califomia.D
Applicant
NOTICE TO APPLICANT'If.aftermnsati this tineas of Exemption.you should
ost
become Subject y the Wortcr7 Compensation provisions of she m Wr Cadee you most
.J Q forthwith comply with such previsions or this Fermis shall W deemed revoked. '
Z` CONSTRUCTION LENDING AGENCY
E-'^ Ihereby alrim that then is a construction lending agacy for the performance of
dhe work for which this permit Is issued(Sec.3047,Civ,C.)
{L7 Q Lander:Name '-
az L ndets Address
U Q 1 certify that I have mad this application and stale that Ne above information u
ly F cones.l agree a comply with all city cod county oNinaa"and sure laws relating to
�U building construction.and bceby authorim mprescmatives orthis city to enter upon the
shave-mcmidgm property forinspection whichpurimses.
(We)agree m save,indemnify and kap harnless the City o(Cupenino again,
UZ
liabilities,judgmcn¢cossand"Perscsin consonsunnec of the grarding of this mit. may in anywayaamc againstmid City
'--' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ,_ ( •t�Q
sOURCEDate ON
Signature ofApplhcanUConor f`{
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applieam or future Wilding aeupanastom or handle hacardous material
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Hcalth and Safcq
Code.Section 25532(a)? All roofs shall be inspected nor to an roofing material bei.
Y. ire p p y g g installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.leis li-am hd all canumiwn as dcfned by the Bay Arca Air Quality Management all new materials for inspection.
District? /
❑Yes pNu
1 have real Ne hvaNnus materials requimmcns un@r Chapler 6.95 o(Nc Califor-
niaHealth&SmetyCwe,Sadon25N)5,25533.d& 534.1 undersand deatiftW building
does oat cum. au a seam,that it u my responsibility m redfy de mxupam of de
require its . uRWmet missaanaaIscahhficieofOc poorer'.. Signature of Applicant Date
(l a
owes mr,tathamsd.gem Dale. All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
46UPEI�TINO
Building Department
JOB ADDRESS: 6033 SV-%O y/ 0j.;-. Z�r. PERMIT# O 6 0 QO G
C ki �Z t y-y. C,A QS*O/`r
OWNER'S NAME: ca,�.��rQ Q�p� j4��n� PHONE # GSb--1IEo—K- ? C,
GENERAFAX #
I am not using any subcontractors:
Signa a 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
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
• C � 4 1 R pCv
Ownere �or Signature Date
CITY OF CUPERTINO
,m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37540003 . 00
DATE ISSUED. . . . . . . : 09/19/2006
RECEIPT # • • • . . . . . . : 36108
REFERENCE ID # . . . : 06090145
SITE ADDRESS . . . . . : 6033 SHADYGROVE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHARLES ROSENBERG & WENDY FAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : WENDY FAN
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
kE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -----L------- ------ - --- ---------- ---------- ------ ---- ------ ----
BPERMFEE VALUATION 2 , 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- -- --------
TOTAL PERMIT 143. 11 0 . 00 143 . 11 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
--------------- - - ------------ - -----------------
OTHER 143 . 11 VISA
TOTAL RECEIPT 143 . 11
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
•
CITY OF CUPERTINO WORC)I �5
�, REPIPE/SEWERS/MAIN SERVICE
CUPOF
ERTINO PERMIT APPLICATION FORM
40
APN # 3�r ^�oO� Date:
Building Address:
C A
Owner's Name: � n Phone#:
L11,11�¢S �oSe� t.va F;,av,,
Contractor: one: License#:
G¢ LT yls-C=C�> -1( � z
Contact: Ch Cry Phone: (05b -157(, Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 'e�
Job Description:
�-
Residential ff Commercial ❑
Cost of Project:
$�e7o.oO
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 Repipe of Fixtures PLUMBING
BPFIXTURE Pb] . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•