08060027 CITY OF CUPERTINO
BUILDINIG DIVISION PERMIT �C�TTOVINFORWATION:
PERMIT NO
j"'L�.'9C/'9V"T'ILSON AVE J.A. CHAVEZ CONSTRUCTION 08060027
OWNER'S NAME; PERMIT ISSUE DAM
gft KATH I E DUNN 593 SARATOGA AVE STE 2 06/04/2008
Iq W15NE: (408) 247-3006 SANITARY NO. CONTROL NO.
ARCHITECT(ENGINEER: BUILDING PERMITINFG
BLDG MECH
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LICENSED CONTRACTORS DECLARATION
I hereby&Man that I an ficcoad under provisions,o(Chapter 9(commencing Job Description
wiMSmMm 70M)ofDivi.mon3ofthelhommusad PrOf4siomCado,saniany liccom is SEWER CLNOUT RMV& RE–HOOKUP
a fail I I ad If
License Lic.8
4t
Co.awcdomrj$ Atis:—7–?!L x
10
q DECLARATION—
I understood my P bass CA2,1M.d a public remals,
mu
t; Licensed Proesm ..I
I beraby firm CatNER,81JIMER DECLARATION
that I an eampt forms Me Cantrachres License Law for Me
C 0 following reason.(Section 701.5.Business ad Prolausions Code:Any city or county
�wE! which an,flost a Permit to construct,alter.improve.ftmolish,or repair my smatuou
poor M its isma...Wo restfulness the applicam for such Permit to rile a signed raturrant
!� Sq.Ft. Floor Area Valuation
��n (cmmcncingwi�S"dm700G)o(Dvision3or�eBuMnm�dftf=ionsC�]or $1800
9 that he ii campt therefrourd ad Me bada far ON alleged mumptia.A.,A.l.d..at
Section 7031.5 by my applimum for A Permit subjects he mpikant to a civil pem.fty,of
nal mom than five hundred d.liba(ML 3 7 5 17 0 4 0 APN Number Occupancy Type
0
and Preafewslons Coal The Commiserates Lictrus,Law doco Out apply or in comar of Required Inspections
p.,n,.ho mildes ori.proves; deessush makhmnalfordoo.gh his
am employants,provided ban such improverecau sm not im, or affected far We If.
however,Me building or improvement is aid within am aner of completion,the Owner.
builder will haw Me burden of proving that he did not build or improve for purpose of
sain I.
Cj 1.as Owner of the property.as exclusively contracting with licensed to
construct Me,project sce.70di.Business ant Pmessi.Coal The Contractors U-
mon,Law does mamply W.Ow.,of ro,xcrty who builds Or Maine.decreem,ad,
who contract Imach paij,cis widt.cortuarear(.)licensed"..at in clas contractors
Lims"L.w.
r-I I an campt under Sa. _,B At P C four this moment
owner Da,
WORKERS COMPENSTnONDEC�RATION
I Malay affirre under penalty of perjury am of Me following declandions:
0 have ad will maintain�Cerii1heme.1'Cmeacm W scif-hout.ficer Woriter,Comen-
a on.es provided for by Semion 3700 of Me,Labor Code.for Mot performance of Me
1�
'u
-1
W w' for which his Permit is[seme.
I have ad will enamutin W.,ker'.Compeasettic.hasursance,as raptured by Smemn
31,of Me Laor Code.far ft perfammance.fMc,wark:far which Mi.Permit is heated.
My Worlom's Compensation insurance"ones and Psiic,,number am
cr. Policy No.:
7C. CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(Thiuseention need not IN completed ifum Permit is forem,hundred alollas(3101)
Or im.)
I CmaiCV 60L in Me puloomerce of Me work for which this Permit is home.I Mail not
I my!-T..I
' fC. , m --mrwn���mbjectw�Woftm'CompcmaUm
eup 7 Ony
Lwa
Ai
Z EN��M�ECI .If. ftf m.05,6ifC..=fl.w of ption.you should
became in the Aces Cone,penestion provisions oftIo 2Codcyoumusi
I x
0 vo map y WL h provismo or this Permit shall b"tand revolud.
z CONSTRUCTION LENDIN6 AGENCY
E 5;
1 baby afilass Must them is 1 construction lending agency for Me fterfoommun,of
the worit for which this permit Is issued(Sm.3097.Civ.C.)
Leader's Nam
Z)z Lender's Address
U C I modry that I have amad this application wall sta,Man Me above informau"is
currents.I agroc in comply with 91 city art County aclimuncess ad sme hom misting to
building comaocooft.ad hereby audscrim mperessenaim ofthis city as carer upon Me
0otne-mcadmand pm,crty for inspection purposes.
(We)agree to save.indconify ad LOOP homeless Me City Of CUPOstirm.gairen
(1) liabilitienjudgracats,costs ad expeoutes which may in my my merane Maust mad City
Z in C..,..O of Me'raffiq of Mir Permit
APPLICANT UNDERSTANDS AND WIL COMPLY WITH ALL NON-POINT Issued by: Date
REGULATIONS
Re-roofs
71al A at ormor Dwe -
H R S MATERIII�fDISCLOSI.IRB Type of Roof
Will "he In ruddi.,occupost Mac.,Media hannadmes nommial
def
defined Cupertino Municipal Code.Chapter 9.12.ad bac licatith ad Safety
Code.Smam.255324)?
CY. All roofs shall be inspected prior to any roofing material being installed.
40 Willdhcttpplicsual,�, unimi.ld! mcm or devices;which If a roof is installed-without first obtaining an inspection,I agree to remove
lah it de OT=Bay Anc.`Ai
haz,ardous air can=:!, as mad r Qualfty,Management all new rnkerials for inspection.
,a
0yes 0 N
I have mm Me mundaus materials requirements under Casino 6.95 Of the Califon.
.is Heath&Safety Code Sectakest 25505.25533 ma 25534.1 unicameral don,if ON building
d.non unreraly havc-amm,thas it is my responfibilil,W rout,ft cup.,Of 0.
require w.c OuLD �7tpmueoism..f.Ccrufic.aa.( re of Applicant
,-7.0 Signatu Date
c.�4, All roof coverings to be Class'n"or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot: .
APN . . . . . . . . : 37517040 . 00
DATE ISSUED. . . . . . . : 06/04/2008
RECEIPT # . . . . . . . . . : BS000004992
REFERENCE ID # . . . : 08060027
SITE ADDRESS . . . . . : 18760 TILSON AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER KATHIE DUNN
ADDRESS . . . . . . . . . . : 18760 TILSON AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JA CHAVEZ CONSTRUCT
CONTRACTOR . . . . . . . : JERRY A. CHAVEZ LIC # 29401
COMPANY J.A. CHAVEZ CONSTRUCTION
ADDRESS . . . . . . . . . . : 593 SARATOGA AVE STE 2
CITY/STATE/ZIP . . . : SANTA CLARA, CA . 95050
TELEPHONE . . . . . . . . : (408) 247-3006
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 11800 . 00 0. 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRSEWER UNITS 1 . 00 20 . 40 0 . 00 20 .40 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 102 . 48 0 . 00 102 . 48 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 102 . 48 VISA
---------------
TOTAL RECEIPT 102 .48
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------- ----------------- - - ------ ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
•
0 00 7
CITY OF CUPERTINO
��✓ REPIPE/SEWER/MAIN SERVICE
• CUPEi,TINO PERMIT APPLICATION FORM
APN #3 �� / -7 6 0 Date
Building Address:
22 5,a.-t 14tIE n-tl��) r4
Owner's Name: Phone#:
-c /viV 3>71 - 44q
n ractor: hone yob' Z/v 3SF-�5—
Fax #&D 7— 30d
Contact: � Phone# VOX Z/U —3
�/�� A- Fax #: (40 ZY7 _ 00,-
Contractor License#: 72 5-0 S� �/ /
Cupertino Business License#: �q r t9
Job Description:
C4--) cP,-
Residential Commercial 0
Valuation: ((( 001
Green Buildin : Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set & the sheet index. -
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
Ask
/ 1BSEISMICR Seismic Residential P
I 1PRSEWER Residential building P. 1RPSS
sewer/sanitary sewer
CITY OF CUPERTINO
« � REPIPE/SEWER/MAIN SERVICE
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
ffIPPERMITFEE Plumbing Permit Fee Issuance PPlumbing Plan Check P
Other Plumbing/gas Insp. P
/ 1TRAVD0C Travel &Documentation Fee B
1BUSLIC Business License B
•
Community Development
F 10300 Torre Avenue
,v- 't' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
SUPEI,TINO
Building De artment
JOB ADDRESS: PERMIT #
�OCO & C� ���tx%o
OWNER'S NAME: 4 N N PHONE g 3 72 — (P 0
GENERAL CONTRACTOR ,C sr,- t� , 14-UF--Z—
I am not using any subcontractors:
Signature Date
Please check applicable subcontr tors d 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
Owner% "ctor ure Date