05070149 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT w, NTRACTTORINFORMATION
BUILDING ADDRESS: ALLSTAR PLUMBING PERMIT NO.05070149
&Rs NAME: PERMIT ISSUE DATE
HAROLD SIPMAN 656 N KING RD 07125-/P00c;
PHONE: SANITARY NO, CONTROL NO.
(408) 251-6040
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0o LICENSED CONTRACTOR'SDECLARATION JobDescri Description
a u I Wrtby affirm that I am Iiceved under previsions of Chapter 9(commencing fries
,Pa „
?iw with Section 7000)of Division 3 of Me Business and Protcssiuns Code,and my license is 11 A I l n B I�LL.
�„ L ranrarteanderr ys '62 INSTALL MAIN LINE WATER SERVICE) FOR.a {��PtOg
>„vj? Liccnu Cl +-E Lica v ar YGI s
'moo Done IP . s amraawr SINGLE-FAMILY DWELLING �a.
!J ARCHITECTS DECLARATIOI
^j w U1 undmsu t>7aayn� ry(I N u os public records
�yy Licanscd PmfrsGG��^a OWNER-BUILDER IDECLARATION
f1 hereby M.shat I em exempt tram Ne Contunors License law for the Ilgss p'
or<a0i ,reason. ei031.5.B ndCale: it, coumy
m0 whichmai.a�emt to ruct.Ann,improve.
mpve.conullirmpsi, annit
ai< prior m its issuance,also requires lW applicant for such permit in file a signed suwment ---
that hcislicensed puatium1aNcpmvisinnsefMeCiouacwr'sLicerse Law(Chapter9 Sq.Fl.Floor Area hValiiati�tp'700
yFa (commencing with Section 7")of Division 3 of the Business and Professions Code)or
i that he is exempt thtrtfrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Fermis subjects the applicant o a civil penally,of APN Number Occupancy Type
not mom than live hundred dollars S500). 32612045 . 00
0 i,m caner ofthe pmpcny,or my employees with wages m their sola compensation,
will do Ne work and Ne swctum is not intended a offered for rale(Sec.7014,Business
and Professions Code:The Canmamrs Li.law docs not apply w an owner of Required Inspections
property who bunds or improves theman,and who dors such work bimseBor through his
awn employees.provided that such impmmmcnu are notinleMed or offered for sak.It,
however.Ne building or improvement is sold within one year of completion,Ne owner-
builder will have the WNen of proving that he did not Wild or improve for purpose of
❑1,as owner of me property am exclusively convecting with licensed contractors to
construct Ne project(Sec.7014,Business and Professions Code:)The Convenors Li
cause law does not apply to an owner of property who Wilds or improves themon,and.
who contracts for such projects with a contractor(s)licensed pursuanuo Ne Contractor's
Liccnu Law.
❑1 am cacmpt under San. .B&P C for this rcawn
Date _
WORKER'S COMPENSATION DECLARATION' --
1 Wmby of am under penalty of perjury arc of me fallowing declarations:
I ham and will maintain a Certificate of Comenuo self-insum for Worker's Compcn.
sation.as pmvided for by Sccuon 37W of the labor Coda,for Ne performance of the -
work for which this permit is issued.
❑1 have and will maintain Worker's Compenution Insurance,as required by Section
37W of Me Lothar Code.for the parfernm nc of the work for which this permit is issued.
My Workcri Compensation Insurance carrier and Policy number art:
Carrier. Policy No.:02
v CERTIFICATE OF EXEMPTION FRO MW RKER
COMPENSATIONINSURANCE
(fhisacenon accord,W completed KIM permit is foram hundred dollars($100)
or Ices.)
1 omfv thm in the parfamautee of the work for which this permit is issued.I shall nut
employ any person in any manner In as;w became subject in Me Workcri Compensation
Laws of California.Date ,
Applicant
NOTICE TO APPLICANT.If,after making this Cenilicate of Exemption,you should
became subject to the Worker's Compensation previsions of the labor Code,you must
.J z forthwith comply with such provisions or this permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F+ I Wmhy allhm that Mere is a coesuuninn lending agency tot the perrmmonce of
D: Bw work for which Btu permit is issued(Sec,3097.Civ.C.)
VJ 0 Undoes Name
a'
UZ Laadcrs Address
U Q 1 certify that 1 have read this application and supe the-the show information is
[i, f" correct 1 agree w comply with all city and county ordinances and sate laws relating m
0U building construction.and hereby authoixe representatives of this city to enter upon the
r� above-mentioned property for inspection purposes.
(We)agme in save,indemnify and keep harmless,Me City of Cupertino against
liabilities,judgments,cosh and exhausts which may in any way acme against said City
in consequence of Bre granting of this Permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE ATIO�
_ Re-roofsf n(�
Sigmwrc of Pli°H ZARDOUS MATERIALS DISCLOSURE Data Of Roof
Will the applicant or future building occupant atom or handle hanrdous material
as d,lncd by me Cupenino Municipal Code,Chapter 9,11,and the Health and Safny
'c.OYes 15532(1)? I fa. All roofs shall be inspected prior to any roofing material being installed:
Will mea applicant m fawn building If a roof is installed without first obtaining an inspection,I agree to remove
pp g occupant use equip ent per devices which
ems hvaronus so-comaminanh JcfincJ by me Bay Area AirQualityManagcmcm all new mate ' Is for inspection.
Drit ha
❑yes
Nu
I have real the bayardnwsm wrials mquimmcnts untkr Chapwr 6.95 of the Califon C
nu Health&Safny Code.Seeuom 25505,25533 aW 255".1 undersand thaziflW Wilding ZJ O
av
docs not earn pew a carol tha maponsibility w notify Me onmpant of the
mquirtments It he p mw' usaccofa Ccruficaw of Occupancy. Signature f cant Date
owner m daWoye ant Data All roof coverings to be Class"B"or better
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT .OPERATOR: kieTsaw
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 32612045.00
DATE ISSUED. . . . . . . : 07/25/2005
RECEIPT #. . . . . . . . . : 30504
REFERENCE ID # . . . : 05070149
SITE ADDRESS . . . . . : 10481 CRESTON DRIVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HAROLD SIPMAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ALLSTAR PLUMBING
CONTRACTOR . . . . . . . : DUARTE TADEV LIC # 22189
COMPANY . . . . . . . . . . : ALLSTAR PLUMBING
ADDRESS . . . . . . . . . . : 656 N KING RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
® TELEPHONE . . . . . . . . : (408) 251-6040
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BENERGY PERMIT FEE 83 .16 39.92 0.00 39.92 0.00
BPERMFEE VALUATION 2, 700.00 83.16 0.00 83.16 0.00
PPERMYTFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BPWSVCS WATER SERVICE 1.00 9.00 0.00 9.00 0.00
___ __________ ----------
TOTAL PERMIT 170.45 . 0.00 170.45 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ -----_____________
OTHER 170.45 VISA
TOTAL RECEIPT 170.45
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 106 SEWER & WATER
507 FINAL PLUMBING
•
x Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�UPEf�TINO Fax(408)777-3333
Building Department
JOB ADDRESS: PERMIT #
royS) os"o p/ `T �
OWNER'S NAME: PHONE # L6cyc, ' 2 Z t OO
GENERAL CONTRACTOR: i W r ti, FAX #
I am not using any subcontractors: 77 2,S IQ S
ature 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 \ 5 rh i —7 3 Z C
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
z5 O
e ontractor Signature Date
05b-4-o14()
CITY OF CUPERTINO
REPIPE/SEVERS/MMAIN SERVICE
CUPEf�TwO PERMIT APPLICATION FORM
APN# Date:
3a(D- a - 0667 2s
Building Address:
IC)LIS e- A3 C ea, N 0) f9sov4
Owner's Name: t Phone#:
CSo c1 .v 4lb8 co
Contractor: Phone: License #:
i M oa 27 - _I oo _732W k
Contact: J � Phone: Cupertino Business License #:
Building Permit Info: ,l v, Amm�&C Wa,
Bldg ❑ Elect ❑ Plumb Q/ J
Job Description:
Residential V Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Pi2ing System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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