06080044 (2) CITY OFCUPERTINO �. � k =�'y'*`"'"' "•�°' ""
BUILDING DIVISION PERMIT COI�ITR"ACTQRTNFURMATION
BUILDING ADDRESS: ABLE SEPTIC PFSMITNo.06080044
21839 LOMITA AVE
OWNER'S NAME: _ PERMIT ISSUE DATE
GARY LEE 520 REED
NE SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHT ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT P MB MECH
0 0 0
0o LICENSED CONTRACTOR'S DECLARATION Job Description
I Wreby affirm Jul I am ns liacme t under prevision of ClupuO
r 9(commencing p
i with Sudan 70W)ol'Dividan 7 of the Business AM Professions Code,and my liamcu
,Oy mfallforaaMeftat. . C77NTS INSTALLING 1 SANITARY SEWER LATERAL, INSTALLING
z License —y2
Damcolramorar, L -L SANITARY SEWER FROM MAIN TO LATERAL, DOMESTIC
Iqq AR CHITELTS DECLARATION
iIuMOntanJ my plain ahallWaedssrecords corJs WATER SERVICE '
Licensed Professional
ry OWNER-BUILDER DECLARATION
I0I I hsoereby.(firm an 1 exempt from 1M Cantracto(s License Law for the
p O fallowing man.(Salon 7 1.onsdav Besmear and Professions Code:Any city or county
I$ which requires a permit re cansuan plan impmsu,do Permit
t or repair aY twmum -
•Zr�^ tprior tohatWitaunsedPUtsu requires the applicant for Cohpermit 1Wm aaiLawOl statement(CIOMW9
: <
(commencing
liccnsMpSesuammthe provisionsDiskC0uslncm iJamcLaw ocode) 9 Sq.Ft.Floor Area Valuation
S tcommendn[with heefromandthebasisfro(NeBuslmsseMon.AnlamCode)ur $20000
Nat be ts exempt therefrom inti d¢bash far the alleged aempdon.Any vlolNan of
Somme 7071.5 by any applicant for a pssell subjects the applicaalso a civil penalty of APN Number Occupancy Type
not mom Nan Bw hundred dollars(S500).
❑I,as owmer of the property.M my employees with wages u Ness WhimMpen'Non,
will daNewanand NeheComrs aAIbcMmaffered.does ctafs«liesno :or ,f -� •.� FequiredIns Inspections
Nd Pmfwho W CMC:Th Can4rM({LIaIlo Des dap int apply m N awmrhis / I 1 p -
proprtywhaWoa,aimpruwathetaaa,aM whOaasauchworkhimrelfmlNon[hnti ! •
Ownempmyua,proWded Nalsmhimprow:menti art Dot lnumWm?BeTed mule
however.Ne building or improvement is sold within are year Of com I tian�eownerv,
builder will naw tie burden of provini that W did ons build or Ire far puryom Of I
pale.). t,. ... � f
Q 1,as Owner of the property,am eaclusively contracting ad Ii=me a e
construct the project(Sen.70",Business aM Profcpdans Code:)Tie Contracm(s Li-
cense law does out apply men owner of property who huilde or imposer demon,and
who contracts for such projects with a conwcter(a)foamed poesmnt to the Comnmota
License Law. .
❑ l an ceempt under Sec .B&P C for Nu mason -
Owner Data
WORKER'S COMPENIA71ON DECLARATION
I hereby afBmt under penalty of perjury am of Ne following dalatations:
I has and will maintain•Certificate te of Consento mif-Insure far Worhe(a Compcn-
ead.,an provided fm by Section 37M of the Labor Code.fm We pdonsames of the ga
work for which this permit u iuued.
❑1 haw and will maintain Workm's Compensation Insunna,u required by Section
7700 of Ne Labor Code,fm the perlbommu a of the work far which this pmol u issued. _
My Warke(s Campwad n Insumna oma and Policy number are:
Grtien POIieyNo.: /JSG/S7_
C a,w�Cp;FICC MPENSATlONINS RANCEORKERS' .
(7Tusccdm aM mtbe compkud if dx person is foram hundred dollars(5100)
or lea)
I aNfy that in the performance of the work for which this permit is issad.I shall not -
employ any person in any manerso as On bcrome subject to Jin Workers'CompenuJan
Laws Of Califomia.Dam
Applicant
NOTICE TO APPLICANT,If.after making this Cmifici m of Exemption,you should
become subject m IN:Worker',Compusadon proWiom of Nc labor Code,you most
wJ O forthwith comply with such provisions m this permit shall W damM revalued. ,
z CONSTRUCTION LENDING AGENCY
gI hemhy affirm Wt dame it a construction la ding agemy far de performanceof
> the work for which this Permit is isrued(Sec.3(19'1,Civ.C.)
W�Q Lender's Name
7 z Lmolms Addrmr
U O 1 comfy that 1 have mad this application and state that de show informatlun is
is, comm.I agree to amply with all city and county ordinances animate laws relating to
0 V building construction,and herby authonre repmscnmiva of this city to cnmr upno the
r W almvementioned property for inapcuon purposes
(We)agree m Mr.,indemnity and karmOe
kap hless City of Cupertino against
y IiabilidesJudgmenu.cau and apnses which may In any way acme aisles,said City
U Z in consequence of Ne limning of this permit.
^ APPLICAf"{r UNDERSTANDS AND WILL COMPLY WITH ALL NON"
Issued by: Date
SGUCP-�7/
�06
Re-roofs
$1[MWrc surA Jammor L+q
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumno hWiding aavpenlmore a handm haurdam material
as de0md by Ne Cupertino
KN.
dal Code.Chapter 9.11.and the Hallh and Safety
Calla,Section 25531(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Will the applicant carWilling attupant tax equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it hnaardom air contaminants m dented by the Bay Area Air Quality MMILANOat all new materials for inspection.
District?
❑Yes Nu
IhawmaJNeha ser dalsrcquimmenuunderC pm6.95oftheC-aliror-
ni.Walsh&SafmyCode,S&-am25505,25533md25534.1undersmndthatifft Wilding
does not current haw a mnen4 Nu It u my responsibility m notify Nc acesyyyyre of tie
mquiremenu .11111 'mWoManaof.CcrdliaMO(CcypaMy,' Signature of Applicant Date
Owner err authorized ppm E-- , DF All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4§UPER,TINO
/Building Department
JOB
-2/FIc3� SCD!'!!/�L /GVG Cv eta �f+ PERMIT #
OWNER'S NAME: PHONE `� 49 — 37
GENERAL CON-IRACTO ll—, G FAX #
I am not using any subcontractors:
CDS
ignature date
Please check applicable subcontractors and com fete 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
Own /Contractor Signature Date
CITY OF CUPERTINO
•m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35716999 . 00
DATE ISSUED. . . . . . . : 08/07/2006
RECEIPT # . . . . . . . . . : 35540
REFERENCE ID # . . . : 06080044
SITE ADDRESS . . . . . : 21839 LOMITA AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GARY LEE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : ABLE UNDERGROUND
CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407
COMPANY . . . . . . . . . . : ABLE SEPTIC
ADDRESS . . . . . . . . . . : 520 REED ST.
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95050
TELEPHONE . . . . . . . . : (408) 377-9990
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- --------- - --------- - ---------- ---------- ----------
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
BPWSVCS WATER SERVICE 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 : 68 . 95 0 . 00 68 . 95 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 68 . 95 4291
TOTAL RECEIPT 68 . 95
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
� II
CITY OF CUPERTINO OWO`cd*
REPIPE/SEWERS/MAIN SERVICE
•CUPEkTINO PERMIT APPLICATION FORM
APN# �-7 — I LO —'9c) Q Date:
Building Address: I
sl fs 3 LOrw40— a.✓V C e-147'✓4-O
Owner's Name: Phone#:
C a " Lit 666 — x/371
Contractor: Phone: License#:
A-.i (< 377 y,7'70 677Y75S cYz
Contact: Phone: Cupertino Business License#:
Azl�be-�— 2r�- o6s 2/ya�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
1;#5&e141Sk,ev 14Aiti1
Residential Commercial ❑
Cost of Project:
f
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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