01020096 CI TYOFNGENPERMIT CONTRACTOR INFORMATION: -
BUILDING ADDR BSS'. P17RMIT NO.
C
OWNaMS NAMI'.: APPLICATION SUB7bA
Id 0ONE.: • SANITARY NO. @)
Te PENNEY 200158 B6GSS AVE
°se% ARCHITI!CIYBNGIEri BUILDING PURMH INFO
00
BLIX'i F.LI:CT PLUMB MECH
z I=1 I=1 f=-I f_I
N j LICBNSIiD CONTRACTORS OBCLARA'1'ION Job Description
I hereby at ill or Incl I am flecn.ed under prev area-of Chapter 9 laoll,lnearing
aF° with Whine m+! rrI.�nJol,lm Bu.ine„anlJy,feroilunn Cmk.a my c
m � is in Gnu folic an et. •���SS 7QY c
oiw� Lian"cla`s 1.i"" _ PLUMBING REPAIR
°i�' -Dam_ -a0_/�I cnmmcwr_
w 3 G ( �I(CHITIiLT'S DI CLAN
C °J I nndernnmd my plan Ball Ire toed:o ramie meedv 1 V L
vo
aa.t,p O Liecnsed Pnnesei"nal -
X OWNPR-BUILDBR DECLARATION
W 1 hereby"flim,thin I ton caempt Phan the Commeor'x Licence 1."w far We
I-z following mama(Section 703 L5,Business and Po rc—m s Code:Any city or coan,y
S€O wlith 4 p It t , 'h pdemolish, p Y.,mctum
,stu, Prorl n, I' 4 ll ppfv 11 hPu. n h g d:ple s,rd
a. - math -licensedp u n p . OImC ,set r. LI Li (Chapter9 Sq. Ft. Floor Area all la•lion
fronmenrim,wth Sett on A(IOIol Division Sof the Barnes, ad Profession,Code) /6
or that he ix risco",Ih act nand the basis for the alleged eseadion.Any vximin i
of Section 7031.5 by any applicant nor a period lubm it the applicant to a civil peasily - APN Number OCCLot
of not more than live hundred dollar($5110).
01,m owner of the prone,or my employees with wages a,theirsole confirmation,
will do the work,and the,tmaum is not intended or offered for sale(Sec.71W,
11........and Prolevxilun Cod,Tree Cnnlmctor'x License Law dnen uoI apply Ia all ` a Cy I ed Inspections
r of property W bo hand,or improve,Ncreor,and who does.such wad Marvell
nr ,through his own employers.provided that such improvement am not intended or
offend tar,me.u:however,the hadming or ropmvcmanl i,.nld within one year of 106 — SEWER & WATER
ouldetion,the owner-builder will lume,he burden of proving,hat he did not build or
n,awefornuy,,coriole.). 202 — UNDERFLOOR PLUMBING
❑I,a.awnluradds,itanpeny.amexeln,leelyeortrallm,withhern,"t lraeao to 301 — ROUGH PLUMBING
Lmsme the project(See.7044,Business and Profession,Cade:)The Contractor., — T!_IB R OR SHOWER
icense I,Iw dusts not apply to an owner of p o,roy who hu:Ids or narcosesthereon, 30�'�
sad who contmcl,for such projwdl with a commcams) Teemed pur,mtnt m the 502 — FINAL PLUMBING ENERGY
Comrumr,Liecme Law.
0 1 mm escand mmler sale. .B a P C far this reason 506 — GAS TEST
Owner °ate 507 — FINAL PLUMBING
WORKI!K$COMPBNSA ION DLCLARATION
I hereby affirm under penalty of perjury one al the following deelanlllon%:
, I have and will m o e
C ,iliculu "f Cnn.un, u, .clnlnmm tar Worker's
Compenmioo, a, prm'ided for by Section 970() of ,he LuM,f Calc for the
perfiamanec ofthe work for which this permit is issued.
01 have and wi i nalinmin Worker',Campenntion I.,mma:e,ax required by Section
3704 of the Laron Code,lin the performance of the work for which this permit is
issued.My Wndcr'r Ct pcm.min i ha-rmme carrier and Policy number aro,
came .poieYNn.:O�ba4�
CBRI'IIICA'I ION O F PXI;MP`oON FROM WORKERS'
COMPENSATION INSURANCh
I'Thin,anion need not be completed if the Iamhit is list nuc hundred dollars
l$I I(1)or loss.)
1 teddy that in the performance aria,work for which this permit is issued,1
.bull not employ any paean in any manner so as m beco"m xah'[ed s,lbu Workes'
Compensation Laws of Cvlifomis.Dale
A'dic a t
NO[IC17 IOAPI'LICAN'I':If. her retaking Icer Cenilicnmof Cxen...I r.you.hotdd
became rbba b,the Workers Conq,en.mian provision of the Labs Cate.You must
Qfonhwith comply will Srich In War,it,this peon!,shall he dcaned ranked.
F = CONSTRUCDON LRNDING AGIJJCY
I hereby atlirmnhat there is n con.tmction lending agency for the performance
w
17 A the ork far which this Pchmi,i,issued(Sts.91097.Civ,CJ
QLender,Name
7 Lender's A,U I,,
U O 1 certify slim 1 have read Inds application and„am that the above alarm:nion is
Lsst... cornet.1 agree u)comply with all city and county luminances and state laws reading
O U m-b itding construction.and hereby amnionic representatives ofthis city it enter upon
} r� the alnve.Incmiooel pmpcnY fur i".prw,ioa namo.I,.
p„ (We)agm•e,save,inJem - and - P hamtless the Cityol Cupcnino against
V) Ila O, ,dgn ems. osu a Ich may in any way uccme against said
U Z Chucna lbs •+tot nthisw ani _
SITUPD. �T DS WI f P.Y WITHA'N P01 i y.- At
Issued b Date
��Sig App cap✓lion a— - Da Rc-roofs
HA%\RDOUS MAITR1ALS DISCIOSURHi
Will the ali,11eaI orarm,building occan:Iot store or ha"me lhmardon no,mdal Type ofRoof
mi -
as defined by the Culna. Ipa1 GChapter 9.12,and the Health and Safety
Section 25532W)'! ds
Cl Yes I No
All roofs shall be inspected prior to any roofing material being installed.
Win the andiram yyyrrr future building ocelpant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
dI h:mudoux hili cmnall'Tynle nn ncroed by the oar niece air Quality Ma"agemcm
,,,,aepre. \.I N" all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have rest he ha.adov,none cyui m Ix ander Chapter ass ill the
Csho
mm"
heal k 'ahoy C ,Seci n,25 f15 _55.3 and 25534.1 understood that
it the M1nllding h nntrrtl hs' conal .t ,n it' nhy q,onnibility,,notify the
hccupml u •reyl nnn
nal it' nue M1 pr',r u, r d o CI�I.f,In a .
alT '— Signature of Applicant Date
anon ar:mt ,rine agent —— Dam All roof coverings to be Class"B" or better
OFFICE
CITY OF CUPERTINO
_• 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: Chris Cya
COPY 4 1
Sec: Twp: Rug: Sub: Hlk: Lot:31620038.00
DATE ISSUED.......: 02/20/2001
RECEIPT q.........: 14706
REFERENCE ID 4 ...: 01020096
SITE ADDRESS .. ...: 10150 N WOLFE RD
SUBDIVISION . . . . ...
CITY .. . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . .. ..
OWNER .. . . . . . . . . . . : JC PENNEY
ADDRESS . . . .. . ....:
CITY/STATE/ZIP . . . : LOS ANGELES CA, CA 90025
RECEIVED FROM . . . . : ALAN
CONTRACTOR . . . . . ..: ANDERSON, DAVID A LIC 4 21988
COMPANY . . . . . . . . .. : DAL REMODELING INC
ADDRESS . . . . . . . . . . : 20058 BLOSS AVE
CITY/STATE/ZIP ...:'HILMAR, CA 95324
TELEPHONE . .. . ....: (209)634-7707
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPWSVCS WATER SERVICE 1.00 8.33 0.00 8.33 0.00
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
•PERMIT : -----43 85 ----0 00 -----43 85 ----------
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ----
CHECK 43.85 8477
..
TOTAL RECEIPT 43.85
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
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