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05070204 (2) CITY OF CUPERI-INO � - = BUILDING DIVISION PERMIT CEONTRACT,0 INFORMATION BUILDING ADDRESS: CUPERTINO PLUMBING PERM1Ty+0.05070204 1165 CRESTLINE DR R'S NAME: PERMIT ISSUE DATE E JOHNSEN JANET E 10297 S DE ANZ ONE: SANITARY NO, CONTROL NO. (408) 253-0618 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �Oo LICENSED CONTRACTOR'S DECLARATION Job Des"cr'lption'11 1 hereby affirm Nal 1 am licensed under provisions of Chapter 9(commencing A LED with Senion)geffecDivision Sof the eusirws+arrd Profcssinm Code.and myliccnse is �- Il I +L„ Lice e.na ren. y (�24 CJOS COPPER REPIPE :::bbb j'a? Liccvc Clux L'e.p q u�t Dale -7 7 Contractor A ARCHECrS DECLARATION TION 4 C 1 undersand my plans shall he used u public reenrds tltlU JyU s Licensed Professional &p tl p p ry 3 OWNER-BUILDER DECLARATION Illr[h'J�JP1' Iuyl r{y�Im �p��fntf 1 hcrchy affirm that I em exempt from the Contractor's License Law for the 11 O O following mason.(&,Gun 7031.5.Business and Profess..Code:Any city or county 5 m which requires a permit or construct,alter.improve,demolish.or repair any structure $5000 _I< pow or is issuance,also sequirct the applicant for such permit to file a signed statement - that x is licensed paramour to the provision of the Contractor's Umnsc Law(Chapter 9 Sq.Ft. Floor Area Valuation yIZ-M (commencing with Section 7")of Division 3 of thc Business and Professions Code)or y $ that he is exempt themlmm and the thesis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of er Occupancy Type tet mom than five hundred dollar($500). ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the wmk.and theMuslim,isnot intended oroffered formic fSec.7W.Business Required Inspections and Prefessimu Code:The Contester,License Law doe e not apply to an owner of 9 P Property who builds orimproxes thereon,and who doessuch work himself or through his own emplayces.provided Nat such improvements are not intended moR«W for sale-IL howeve,the building ar hnprorcment is sold within one year of completion.Ne owner builder will have the burden of proving that M did not Wild or improve for purpose of nlc3. Q 1.as owner of the property,am exclusively contracting with licensed e m e,mrs to consumer Ne project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense law does not apply to an owner of property who Wilds or improve thereon,and, who contracts for such projects with a con=fan(s)licensed pursuant to the Contractor's Lice se Law. ❑lam camin, mh,r See. .B&P C for thisO muton « Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of dm following declarations: [ham and will maintain a Cenilcate of Consem to self-insure for Worker's Compm. sudor,as provided for by Section 3700 of On labor Code,for the performance of Ne work for which this permit is issued. �L/1 have and will maintain Wmlut,'a Ci mperwtion Insurance,as required by Section M' of k e labor Cade,for dm pert.C I of the wars fm which Nu permit is issued. My Workers Com�peyR tion Insurance caa/n«and Policy n pm rare: ,s Carrier. �Cr lsae ��G' Polity No.: Urll/�fAJ� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(SI00) or less.) 1 certify that in the performance of the work for which this permit is issucd,I shall not employ any person in my manners as w become subject u the Workers Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should become subjoin to the Worker's Compensation provisions of the Labor Cade,you most Z forthwith comply with such pmvisions or this permit shall W deemed revoked. z CONSTRUCTION LENDING AGENCY PIhereby affirm that there is a construction lending agency for the performance of a the wink for which this permit is issued(Sec.3097.Co.C.) Lenders Namc ,Z Lender!Address U Q 1 comfy that I hate read this application and sate that the above information u V. P Correa I agree to comply with all city and county on inanm and spite laws misting to 0U building construction.and hereby authorim represenenivn of this city to enter upon the above mentioned property for inspection purposes. 4 (We)ague to save,indemnify and keep hatmlees the City of Copertinu agsinat F fn liabilities,judgments,Cwt and expenses accrue which may in MY way against said City U Z in eonmqupncc or the gstring of this permit. ^ APPLICAN7,UNDERSTANDSL COMPLY WITH ALL NON-POINT Issued by: Date SOUR G L O NS. ( n —l. Z'>-19 S` Re-roofs w of pls C vat Date CR OUS MATERIA S DISCLOSURE Type of Roof Will the applicant tar Tut lding occupant amrc or handle havardous material as defined by the Cupertino Municiral Cod Cha Chapter 9.13.and the Health and Safety dc,Section 25533(a)? o All roofs shall be inspected prior to any roofing material being installed. p Ycs Will tiac applicant fuwm building wcupam use equipmem ar devices whicM1 If a roof is installed without first obtaining an inspection,I agree to remove emir ha'vrdow air cnnamimmus as defined by the Bay Area Air Quality Management all new materials for inspection. D strict? ❑Yes /�u I hsmre Ofh m(sma¢rials¢yummcros under Chapmr6.95 ofthe Caliror Ole Hcalth&S e"C ,Sectiues 55(15, 533sm125534.1mearsmndlhazifthe Wilding due nal err nti/to at it i my responsibility to notify the meupant of the requimmcn w¢h t n panceofaCertificate ofOccupancy. Signature of Applicant Date _( own auth iced agent Date All roof coverings to be Class"B"or better Community Development �f 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 �JPEf�TINO Fax(408) 777-3333 Building Department JOB ADDRESS: PERMIT # _ OWNER'S NAME: PHONE # GENERAL CONTRACTOR: 1 urnbi n FAX # 1v� 2530 I am not using any subcontractors,:,- -7, 7--=7 , 6'� Si 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 U f Roofing Septic Tank Sheet Metal Sheet P)-CV Til caner/ ntr to ignature Date CITY OF CUPERTINO I 1 of 1 PERMIT RECEIPT OPERATOR: suem COPY # 3 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36229037.00 DATE ISSUED. . . . . . . : 07/29/2005 RECEIPT #. . . . . . . . . : 30582 REFERENCE ID # . . . : 05070204 SITE ADDRESS . . . . . : 1165 CRESTLINE DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : JOHNSEN JANET E ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5034 RECEIVED FROM . . . . : CUPERTINO PLUMBING CONTRACTOR . . . . . . . : CARDIA, FRANK L LIC # 612 COMPANY . . . . . . . . . . : CUPERTINO PLUMBING ADDRESS . . . . . . . . . . : 10297 S DE ANZA BLV CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 ® TELEPHONE . . . . . . . . : (408)253-0618 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL BPREPIPE NO OF FIXTURE 1.00 9.00 0.00 9.00 0.00 PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 __________ __________ __________ ---------- TOTAL PERMIT 47.37 0.00 47.37 . 0.00 METHOD OF PAYMENT AMOUNT NUMBER ------------------ CHECK _______ __CHECK 47.37 1181 TOTAL RECEIPT 47.37 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ________ __________ ________ _ _----_______________________ 301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING CITY OF CUPERTINO ' REPIPE/SEWERS/MAIN SERVICEITY CUPEkTINO PERMIT APPLICATION FORM APN # 012Y Building Address: 45 Owner's Name: (� Pho e #: J Jc>hn�h LOS ;67 - 5-) L/ Contractor: re, ` n License #: b n LI e�as Contact: Y Contact: n _ I J I y`J��3_ �/G Cupertino Business License #: Building Pennit Info: A p(Pet— (-11:f � Bld ❑ Elect ❑ 1' Plumb Job Description: Residential Commercial ❑ Cost of Project: �GGO Qty. if Applicable Fee ID Fee Description Fee GroLl i PPERMITI EE Plumbing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPERMFEE Bldg. Permit Fees BUILDING BPFIXTURE Pbl =. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING B PS E W E R Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING