06070053 (2) CITY OF CUPERTINO 1. &six7-77-7777777,17,7777, 77
BUILDING DIVISION PERMIT CONTRACTnR INFORMATION
BUILDING ADDRESS: PERMIT900 6 0 7 O O 5 3
19231 PHIL LN
OWNER'S NAME: PERMIT ISSUE DATE
VAN TRAM
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i0o LICENSED CONTRACTORS DECLARATION lob Description
C I hereby affirm Nat 1 am licensed under provisions of Clasper 9(ions.img
etW with S.Nw70DI))ofDiveon 3 of the Business and Profcssima,Code,and my tic..is
±�„ inmBfneeandeffa ���7��Z_
TEMPORARY POWER
v�z Leena Clan Lic,g
F p Deu f2 Contranor
s S ty ARCHITECTS DECLARATION
9m� I understand my plans dull W used as public rooNa
)n'e�y Licensed Professional
OWNER-BUILDER DECLARATION
<f 1 hereby alTirm that I am exempt from the Conuamafs License Law for the
p O following mason.(Section 703 1.5,Business and Profcu;nns Cade:Any city at county
<m which requires a permit to ennso et.aimprove,demolish,or repair any suumure 1
u2illey,
prior O its ismance,also mgaims dM applicant far such permit to file a signed statement
< that he is licensed paovanuotW pm.isiom of the C.mramts Liwme Law(chapicr 9 Sq.Ft. Floor Area Valuation
Y.0 (commencing with Sermon 7000)of Division 3 of the Business and Professions Come)or
y $ that k i,morpt therefrom and the basis for the alleged eaewpdon Any violation of
$action 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not mom n five hundred (5500), er Occupancy Type
dea
I.u owner of the property.or my employees with wages as tW'm sole compemadon,
will do the work.and themuc oro is not intended or offered for Sala(Sec.7W.Business
and Pmfessiom Cade:Tho Conaxter's License law does ver apply in son owner of Required Inspections
property who Wildsorimproms theswn,and whodoessuch work hunulforWmugh his
own employcess,provided Nat such improvements ase not intended aroffered for We.IL
however,the building or improvement is sold within oro year-of completion,the owner.
builder will have IW burden of proving Nat he did not Wild or improve for purpose of L�
ulilde
❑1,as he,of the property,am exclirdvely emaructing wild licensed coma cbn b
consumer the project(See.7044,Business and professions Code:)The ConuamWs Li-
cense law dos or apply to an owner of property who Wilds or improves IW mon,and
who contracts for such projects with...."clods)licensed pursuant to the Gm aruies
Licence law. Flo
❑Ions exempt under See ,B&PCfm Bus reason
Owner Dau
WORKERS COMPENSATION DECLARATION
I hereby afrum under penalty of perjury,am of the following daclmauanc
I hem and will maintain a Cen ficae of Consent or self-imam for Worker's Cast
sation,as provided for by Sertion 37M of the Labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Campematim Inurence,as requ;md by Section
37W of the Labor Coda,for Ne performance of the wart for which this permit In issued. '
My Wmkets Countersuit..buurxsee.nim and Policy number am:
Cannot, policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(Ibis second need tat W cmnplewd if the permit H froom WndamdduBes(5100)
or less.)
I certify,that in use performance of the work roo which this pe if'u issued,l,hall net
employany'perunin any manner b Nhe sit jac a 'o ri Compensation
Laws of Glirmen..Day
Appliam____a_egj
NOTICE T0,A, GANT:If,.a r N7 cnificate of Exemption,you should
become suhlm m the Warkfta C➢ putswuh n provisions of the Labor Cade,you must
.J z forthwith comply with such provisions or Out permit shall he domed revered.
OCONSTRUCTION LENDING AGENCY
(~ IWrehy.M.that Bert isit.mameuan lendingagency for be pelleare ceof
a > the work for which this permit is issued(Sec.3197,Civ,C.)
QLeodcfs Name
z Landefa AM.
U 0 I certify dist I have read this application and some dist the above iNomuuw is
I, f-' emmm.I agrce in comply with all city and county oNinsnces and state laws plating in
0 U Wilding conswnim.and hereby amhmm rtpmsenmivrsof this city mcmcr.pnm the
r0. ,havc.mwudgmed propcst raninspection which may
(We)agree reeve,indemnify and keep harmless the City of Cupertino against
H h liabiliues,Judgmcnts,casss and expmons which may in any way ucrne against said City
U z in consequence of the granting of Nis t./
^ APPLICANT UND D WILL COMP Y'WITH A NO OINT Issued by: Date
SOURCE REG S.
Re-roofs
Signature ofApplic o r Date
DOUS MATERIALSDICLOSURE Type of Roof
Willi applicantarfuture Wildingoccupantstaeorhandle hacudedumaterial
u dcOn til by the Colima-Municipal Code.Chapter 9.13.and the Health and Safety
Code,senior 35533(,)+
41 ❑Yes ❑N. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or futum building occupant raw arpurra d or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air conuminanu as dcrined by the Bay Mea Air Quality Management allnew materials for inspection.
Diaoict7
Oyes ON.
I have real Ne hvaNsms materials requiremcnss under Chepterb.95 of the Gli(ory
Na Hcal"Safcty Code,Secuons35505.35533and3)534.luidenunddutifde Wilding
Jots not currcndY haw acount tie isGy nsibility in notify the upon ftW
myuimmcnu m err i e ,eemreatear van . Signature of Applicant Date
Tar, ze a D,e All roof coverings to be Class"B"or better
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: kier5aw
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37540047.00
DATE ISSUED. . . . . . . : 07/11/2006
RECEIPT #. . . . . . . . . : 35200
REFERENCE ID # . . . : 06070053
SITE ADDRESS . . . . . : 19231 PHIL LN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : VAN TRAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : VAN TRAN
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
IRE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
______ _____________ __________ __________ __________ __________ __________
BTEMP FLAT RATE 1.00 62.10 0. 00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 100.47 0.00 100.47 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ _____-____-_______
CASH 100.47
TOTAL RECEIPT 100.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 304 ROUGH ELECTRICAL
•
CITY OF CUPERTINO
TEMP POWER
CITY OF
•CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
O
no
Name: Phone#:
4�10,09-:?IV9a
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Elect Xi
Job Description:
Residential Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Tem orary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
•