04120106 (2) CITY OF CUPERTINO
B.WILDINC DIVISION PERMIT CONTRACTOR INFORMATION ",:
BUILDING ADDRESS: _ CUPERTINO PLUMBING PERMRN004120106
7791 ORION PL
" M'S NAME: PERMISSUE DATE
NITA SHAH 10297 S DE ANZA BLV 12 /1 �/2004
PHONE: - SANITARY NO, CONTROL NO.
(408) 253-0618
-
ARCHITECT/ENGINEER: BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION O O O O
I hemhy&Rrm Nat I am Iicenseu under provisions of Chapter 9(commencing - lob Description
Z with Section 7"WDivision 3oflM Business and Professions Cede.and my license is ,
enfowandcrf k � ��7 �� WATER SERVICE
j ra IAanw Clw Lie.p �i_,,`�`*�
Dam 17- f1 - S'-r ry Comranor -
ARGI{all�hc u�.scd u�ubi'cr ION
^€ I and and�y/�IId,a 1
'Z LLo tj cs
LICCnsc PNf 0 I�
3 OWNER-BUILDER DECLARATION
ane
F.0 F 1 hereby.M.Sect on 1 1. .Bumpe from the Canlns Cou License taw Tor she
ipD followhich re mason.(Section 703 oactur Businessand ove.Professions Co de:Any city or county
which requires;issuance.permit ac cores the alter,improve,dcermiti or repair ed asum m
tZ} last mslensedpelta acquires theapplicantsof rM Co permit in BICs Law(Chapt en1
a Nathe menccenud pursuant of Division
of thea B.sicmr'salpoli Law Cram)or Sq.Ft. Floor Area /j r/t Valuation
(rot he
(commencingwithSection 11Indth D ass far of Be Bu CACelp Professions Cade)tar -
y�$ titer he u eumpt tgemfrom aM the bssh for Ne elkgrd eumptiw.My violation of
Section 7031.5 by any applicant for a permit subjecu the applicant to a civil penalty ofot un e 0 -� OCC
nroam dfive hundred dollars(3500)_ - ,--Occupancy Y Type
❑1,as ow.of the Property.or my employees with wages as limit sole compensadon.
will do the work and use structure is not inkrlded or offered forsake(Sce.1014,Businev
' pp�[ions
and Pmfwions Code:The Contrumi's Liceane Law does,rot apply wan owner of Required
property who brilliantimproves lhereonand wh.dwuwh work himself.through his - 46 ��] -
ownemployees.Provided NalsmhimprmememsamnotimmndedaraRemdforsale.IL
however.lie building or improvement is mid within am Sear of compledon,the Owner.
Witter wiH have the burden of proving that he did not build or improve far purpose of -
sak.).
❑1.as owner of the property,am exclusively contracting with licensed comnanm in
construct dm project(Sec.7044.Business and Pmfcamns Codc:)The ConracmYs U.
coons law doss not apply in an owner of property who builds or improves Nemon.and ... .'- _....
who contrmis hu swh pmjecu.ith a cmmrOcmo(,)Iic mscd pursuam to the Communes
Liceve Law.
❑I am aarpt under Seo ,B@PC for this
Date
4 IF WORKERS COMPENSATION DECLARATION . -_ , . _.• ..
I hereby affirm under Penalty of perjury arc of the fallowing declarations: '- -
0lhaveand will mainuinaCcnifiwmof Conunuoulf-insum for Workers Compon. '
section,u provided for by Section 3100 of the labor Code.far du performaax of Ne
work for which this
permit is issued,
I'were and will maintain Walker's Compensation hues morn.as required by Section
W of Ne tabor ONISA the performance of the work for wbich Nis permit u issued. _
My WorkeYs Compensatiomno Insu��ran/ce carrier and Polic..y..ynr����uymbvvvvversa..m��:
Ca anarsia'j'e ��G PolicyNo
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITh rcaiw wed nos he completed if the parmil is forma hundred dollars(SIM) ..or less.)
1 canter that in the performance of the work for which this Permit is issued,1 shall not
employ,any person in any marmru as in become subject to the Workers'Compensation
Laws of California.Dam '
Applicant
NOTICE TO APPLICANT:If,after making this Ccaificak of Exemption,you should
become subject m the Wortma Compensation provisions of thC labor Cods you muss
.J z foMwith comply with such provisions or this permit shall W deemed revoked.
'Z O CONSTRUCTION LENDING AGENCY
[x 1 herby cram than them I..m (Sec.3 n lending agcwy 1'nr Nc perfurmmcc of
CG the dark for which Nu permit h issued(Sec.3091,Civ.C.)
Qndefs Name
U
z LcndcYS Address
U 0 1 certify that 1 have read this application and sum Nu the above information is
I, F' correct.I agree to comply with all city and county nNinanms and sure laws miming to
0 U building cons action,and hereby audition,mpreunutims of this city to enter upon the
shava-bmil6 cntioned gmcn"cny for iaspcction purposes.
LL (We)a o-lomw,indemnify and keep harmless the City or Cupertino against 1
UV] liobiliti gmcnu,cos and efuh s pewhich may in anYw'aYa¢rw agaiestacid City
Uz inc wwc of cg tiNDSthisDWIL Issued by: Date
LIC DE T NDS AND WILL COMPLY WITH ALL NON-POINT
d. 5 5.
/2 -!S, y Re-roofs
Sign Applic rCantnaor Date
AZARDOUS MATERIALS DISCLOSURE Type of Roof
c applicant or future building occupant some or handle hmudous mamrial
rFj� the CupertinoMunicipal Cade,Chapter 9.12.and the Health and Safety
^ 35332(x)? All roofs shall be inspected prior to any roofing material being installed.
N
If a roof is installed without first obtaining an inspection,I agree to remove
Wdl the app's I or fawns building xcupam esu cyuipmwt or Jcvicns which g P
emit hawdous air contarrinanu as dernad by Ne Bay Amo Air Quality Management all new materials for inspection.
District?
❑Yes ON
1 hove maJ Ne henNouxmamrialsmquiremenu under Chepar fi.YSof the Caliror
nit afety Code.Secmma25505,25533andn334.Immersunl thaifthe building
wtCoo`polyl maW'amt.floss it h my relpeoibility b Mof,im..P.,or the
mgai i m 1pimmissuanwaff Certifc}to r0ccupanq. SignatureofApplicant Date
OJfiel or ushmiumd agent / 2 (S All roof coverings to be Class "B"or better
CITY OF CUPERTINO
Ie 2 of 3 PERMIT RECEIPT OPERATOR: quem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 36218048.00
DATE ISSUED. . . . . . . : 12/15/2004
RECEIPT 4. . . . . . . . . : 28060
REFERENCE ID # . . . : 04120106
SITE ADDRESS . . . . . : 7791 ORION PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : NITA SHAH
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5078
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
BPWSVCS WATER SERVICE 1.00 9.00 0.00 9.00 0.00
__________ __________ ----------
TOTAL PERMIT 18.00 0.00 18.00 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 106 SEWER & WATER
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
J, Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�JPER,TINO
Building Department
JOB ADDRESS: -7 -7,71 Dr rar'1 � PERMIT # 60 z a)0 G
OWNER'S NAME: S{ -/ , /L;/ PHONE # 2!�-7 5- r-)
GENERAL CONTRACTOR:(' FAX# 2S3 Cl. 73
I am not using any subcontrac ! . /'� 'If •/) l
Signature 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
C Plastering
I Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile /1 ^
�_e /Contractor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE l7qlgoO
• OF
CUPERTINO PERMIT APPLICATION FORM
APN # ate:D
l2-iSC�y
Building Address: (
Owner's Name: Phone #:
AA
Contr r: Phone: License #:
iqQqUff+ s-
1 act. hone: 3 Cupertino Business License #:
�— 1'Z l
Building Permit Info:
Bldg ❑ Elect ❑ Pltrmb
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Gro
up
PPERMITFEE Plumbing P=FeesBUILDrN(-,
BING
BPREPIPE Re i e of FiMBING j
BPERVIFEE Bldg. PermiDINGBPFIXTURE Pbla. FixturBINGBPWSVCS Main WaterBINGBPSEWER SewersBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
I