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041000661 L0, nF� Y, 30 in �p0 wm4 FZa XcFcin LT! Oz Z a>_ aQ UO OU U F� �z CITY OF CUPERTINO Bu1t,Dlnc olvlslon PERMIT 7GQN7,'RAGT�11,2I FQRMATION,. ,; BUILDING ADDRESS ABLE SEPTIC PERMIT N94 10 0 0 6 6 0245 STEVENS CREEK BLVD OWNER'S NAME: PERMIT ISSUE DATE S.J. MYERS 520 REED ST. 10/12/2004 HONE: SANITARY NO. CONTROL NO. (408)377-9990 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION 9 Job Description I hereby affirm that I am licensed under provisions of Chapter (commencing withse rP WIBof Division3nfthe Bu'nessand Professions Code, and my license is in fall in ai ( NEW C/O / License Class Lic.p �7g1701 Data i 0.— Q— Contractor ARCHITECTS DECCA�ATION �Hoderamnd my plans shall he used a public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law I'or the following reason. (Section 7031.5, Business and Professions Code: Any city nr county which .,at. a permit ,, construct, alter, improve, demolish, nr mpair any sumo and $5382 Prior ser its i.csnancc, also requires applicant for such permit to File a signed statement that he is lianud pursuant to the provisions of the Commuter's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7") of Division 3 of the Business and Professions Crile) or that he is exempt tnemfame and the basis fur the alleged exemption. Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of' b Occupancy Type oat more than five hundred dollars (s500). 0 1, as owner of the property, or my employees with wages as their sole compensation, do the andor altered fors ale (Sec. 7044,Bear ne will dothPwmk, andth Required Inspections fork will Livens The Conmctoti License Law tlas nut apply man owner The Contractor's :IN property who builds or improves thereon. and who does such work himulfor through own employees, provided that such improvements are not intendetl or offered for sale. ` however, the building or improvement is sold within one year of completion, the owner- huilder, will have the burden of proving that he did not build m improve fur purpose of sale.). P9 2004 exclusively Professions i. ❑ Las owner oftheSec.7 OCT Cwild ode:) no cense theProjectnot (Sec.7044,Businessand Professions Codc:)The Convacmr's Li. ,B Contractor's La cense Law docs not apply to an owner of property who builds or improves themun...{{{ who contracts for such projects With acnntmemrts)licenutl purauam to dm Contras �/ G eau law. ��®I �cl am exempt under Sec. ,B&PC for this ro i^7 0 Owner Date WORKER'S COMPENSATION DECLARATION I hereby alllrm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Cenilleme of Consent o self -insure for Worker'sCompcn- sation, as provided for by Section 37W of the Labor Code, for the performance of the work for which this permit is issued. ❑ I he" and will maintain Worker's Compensation Insurance, as inquired by Section 370.ppppppf the Labor Code, for the peofrrmanm of the work for which this permitis issued. - - Mrkcr's Compensation Insurance canicr and Policy num,hAera�tkm^: CERTIFICATE OF EXEMPTION FROM WORKERS's COMPENSATIONINSURANCE (This section head not accompleted 01/hc Permit is fount hundred dollars(1100) ,It less.) I cenify, that in the pearonnance of the work for which this perm it is issued, I shall not employ any ed rson in any manner so a m become Subject n the Workers'' Compensathm a Laws of California. Date Applicant NOTICE TO APPLICANT: If, arm, making this Compeatc of Exemption, you shnuld become subject to the Worker's Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall M deemed revoked CONSTRUCTION LENDING AGENCY 1 hereby affirm Nat them is a consumption lending agency far the Performance of the work fur which this permit is issued (Sec. 3097, Civ. C.) _ Lender's Name Lender's Address is and sura that the able I agree that) have mad thiscity bonding 1 agree to comply with all city and county laws and state laws r construction,tioneand hereby amnonp representatives of this city m tomo upon the natives of upon ( e above-mding above-mentioned property for on purposes. agree deadmicti (Wo) agme ro save, indemnify and keep harmless the City of Cupertino against liabilities, Judgments, costs and of thisexpenses permit. may in any waysame against said City of the granting of this permit. A APPLICANT APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGULATIONS. Re -roofs Type of Roof fir- '�as.2 1 1(� � t/ z- are ^J2-0" SiCbamrc of ApplicaH nCARDOU % Dam HAZARDOUS MATERIALS DE CLOSURE Will Ne applicant or (Muni building or handle material e. Cha�ore az defined by the Cupertino Municipal Codc, Chapter 9.13, and the Health and Safety Health a � Coca , Section 25532(a)? ❑YPa Nr All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which Lot monotones air contaminants as darned sty the Be, Arca Air Qualhy Management all new materials for inspection. District? ❑Yes �INo L4 1 basic mad the has dims materials requirements under Chapmr 6.95 of the Cold., nia Hcalth&Safety Cod, Sccdons25$)5.35533and25534, leadersundthmiftM building - da not cmremly how a tenant, Not it is my responsibility at anuly the aeupant ol'Ne requircmenls which must M met Pdor to issuance ora CCNfcam of Occupancy. -hose Signature Of Applicant Date t ,- Los, sots 'Cr J Z All roof coverings to be Class "B" or better Owner or authorized agent Data CITY OF UPERTINO I am not using any subcontractors: Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408)'777-3333 artment Signature Date Please check applicable subcontractors and complete the followine information: o cJl �(` ✓ Z Owner/Contractor Signature lo -12-01-1 �� Date 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 o cJl �(` ✓ Z Owner/Contractor Signature lo -12-01-1 �� Date 67 OF CUPEkTINO CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE PERMIT APPLICATION FORM bgo/ =>�4 ,d APN # l 2, Date: Building Address: 2-02-14Se s Owner's Name: �• y Phone #: Contractor: Phone: License #: Contact: Phone: Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Job Description: Inc estdential ElrJR04 CQrnn ercial,_ Cost of Prniert• BPWS Fee ID AGE 5, 392-a0) Plumbing Permit Issuance Repipe of Fixtures Bldg. Permit Fees Pblg. Fixture Main Water Service Sewers Fee PLUMBING Z73 7/ r m 1 of 1 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ......... 31625043.00 DATE ISSUED.......: 10/12/2004 RECEIPT #.........: 27391 REFERENCE ID # ...: 04100066 SITE ADDRESS ..... SUBDIVISION ...... CITY .............: IMPACT AREA ......: OWNER ............: ADDRESS ..........: CITY/STATE/ZIP ... 20245 STEVENS CREEK BLVD S. J. MYERS U OPERATOR: conniew COPY # : 2 RECEIVED FROM ....: MILLER & GIBSON CONTRACTOR .......: GILBERT, GLEN LIC # 21407 COMPANY ..........: ABLE SEPTIC ADDRESS ..........: 520 REED ST. CITY/STATE/ZIP ...: SANTA CLARA, CA 95050 TELEPHONE ........: (408)377-9990 •FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL BPERMFEE VALUATION 5,382.00 126.36 0.00 126.36 0.00 BPSEWAGE UNITS 1.00 67.14 0.00 67.14 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 ---------- ---------- 253.45 ---------- 0.00 ---------- 253.45 0.00 METHOD OF PAYMENT ----------------- AMOUNT NUMBER ------------ CHECK 253.45 ------------------ 8375 TOTAL RECEIPT 253.45 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 •