06060248 (2) CITY OF CUPERTINO
BUILDING DIVISION PER IT �t-QNTkXGTOR,I INFORMATION-. ,,�
BUILDING ADDRESS: uuPEx'riN(_) PiXMIBING PERMIT NO.06060248
1128 STAFFORD DR
OWNER S NAME: PERMI'17ISSUEDATE
DON FERRIE 1300 DELL AVE, STE C 06/29/2006
NE: SANITARY NO. CONTROL NO,
(408) 253-0618
ARCHITECTIENGINEER: BUILDING PERMIT INFO
FILDC MECH
C=
LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby adfirm that I and licensed a.&,PrOvituds;of Chapter 9(commencing
;�MOr with Section 7")of Division 3 of dus Business and Profiessiond Code,no my license is
M On in full force and cV5,t GAS LINE TO FIREPLACE
�Lj� Lice la-Z 1�1:
;�:, Dow - -
ARCHITECTS DECLARATION
I..churararad my ph.shudl he used.public reemch;
to Licensed Professi...I
0 OWNER-BUILDER DECLARATION
I hereby afford that I am exempt from thc Convector's Uccnw Law for the
00 WkwAr,..a.(Section 703 I.S.Business and Poeftnotimss Coah:My city or court,
2� which recidiren.Nonni,.cannontei,.1tsur.improve.dcasofials,or repair any structure $50
v. prior at its issuance,also requires the applicant far such Pamir to file a signed statement
that he is licensed ...at I.due,proAtutma of use Contractor.License Law(chapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section 70DO)of Division 3 of the Business and Professions Codic)or
that he is exempt doundfrand and the India for the ailOged exception.Any violadi om of
Section 7031.5 by any applicaunt few a permit subjects the applicant to a civil penalty of er Occupancy Type
no,..th.five hundred doilart($5013).
0 1,. .Of the Property,Or my amphty..with wages;as their sole compensation.
will do dre,work.and the structure is not amended or offered for safe(See 7044.Business
add Porlossi-ad Cod":The Ctodurectur's License Law does an,apply ad an Owner of Required Inspections
property who builds orimprovea diteread.and who doessuch wark hicusallorthrough his
Own employeas.Provided that such improvements ar,not inten Vzzh
hxwancs�due building or Improvement is sold within one yestar roo.off=llor=
build),,will have the burden of inevir,Our 1h,did rum Wild or improve for Inufma,of FINALLou
asho .
0 1. a do,of the property,....ck000l,connecting with licensed mmoderstrat I.
construct the project(Sec.71],04.Business;and Proollessiom Code:)nic Contranesor's U- 2006
cc=Law does not apply un in owner ofiareptarty who Wilds or improves thercon,and
who contracts for such projects with a commuctor(s)liccesod'unatual an be cosor.cla".
License Law
0 1..tocarpt ad&,Sec. —,a&Is C far do,
Owner Data
lJ6515, LOOP
WORKER'S COMPENSATION DECLARA�ON
I bereby ffirse under peoulty,of peryary asse of ft following declarations:
I have and will maintain a Certificate of Consent to self-incom,for Waders Compon-
satimt,ass proviclud(a,by Section 37M of he Ladoor Cetus.far the peafame.Of the
woult,for which this incrout I.Issued.
F1 I have add will co.i.cam Worlde?a Cconperounflom Itcheranct.sa depinted by Scdod
37M corthe Latter Code.W the performance offt work for which this Norman issued.
My Warloca's Compectuadion Insurance carrier and Policy number am
C"Oh". policy No.:A/d)r;'—
;SCEMFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(nissection need not he completed if the Permit is foram hundred dollars($103)
less.)
I ecruit)v that in the parfirmance of the work for which this Parent,is Wood.I shall not
cropi.y.dy person i.an.Or san ne,rao.in tacconx subjoct us the Wmiters'Conniscounsithod
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.apor mudding this Certificate of Exemption.you shoddhi
become subject to the Worlicr's Compensation previsions of dre Labor Cuts.you most
z ectswids Comply with Such Proviniona M this NMiL shall the deconed raveled.
z C
V
3 CONSTRUCTION LENDING AGENCY
I hareby affinat that them I..c..Iina icruli.,agency for use,Pufarrommuctsf
the annit for which this permit I,Issued(Sec.3097.Civ.C.)
Lender's Name
Urader'sAccul.
z
U C I catify that I have ad this application add sude that dre.1owc milemintai..is
L, t— comet.I agree on comply with adl city and county ordinances and auste laws miming 1.
0 ou ilding constroction.and hurclay authmire ocipmsco adives of this city to enter upon the
U above-mornioncd prop,rly for inspection purposes.
0� (We)agree to an.indemnify and lonp loundleas the City Of Cupertino!gacla a(
i,i liabilides.judgmenuscosts and expeouts which may in my way accrut,against said fty
U Z in consencluerace of the Strominif of this permit.
APPLICANT UNDERSTANDS AND WIL MPLY WITH ALL NON-POINT Issued by:S4(0z:a_d Date
�URCERE
7 Re-roofs
m t."OK Date
A�R!%TjS MATERIALS DISCLOSURE Type of Roof
Will don applicant or tot=building occupantstone or handle houtandous material
as dchned by tho Cuperino Municipal Code.Chapter 9.12.and the Hcadidd and Saraty
Coale.Section 25532(a)?
El Yes EIN. All roofs shall be inspected prior to any roofing material being installed.
Will ft applicant or future building Occupant use equipment or dcvico�which If a roof is installed without first obtaining an inspection,I agree to remove
..it h.rdi it cormoommuds as d,linn!by do,111,Are.Air Quality Mfuns,entem all new materials for inspection.
Dicarl"?
r'l Yen 0 No
I have read the hossudem,materhh m,porcurcruh under Chapter 6.95 ofthe Calirm,
.is Hc.1da&Safety code.5;cuums 2553S.25533 and 255�1.1 tunicescoul dhat if he building
drea.3 caneroll it 4 my responsibility an notify tho occuposem of be
m re re ..I I croficate of Cecupancy Signature of Applicant Date
vme��cn,M a,c—nr Date All roof coverings to be Class "B"or better
,,,,, Community Development
10300 Torre Avenue
M/' Cupertino CA 95014
Telephone(408) 777-3228
CITY Of Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
Ia 8 5-t �r,4- z2 60 6a'2Z-
OWNER'S NAME: rt_ PHONE # ;2- ?_ lepF U
GENERAL CONTRACTOR: ,, (U FAX #
I am not using any subcontractors: G Z? -Ifl(r
ign a Date
Please check applicable subcontract s 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
nq(/ actor Signature Date
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36207013 . 00
DATE ISSUED . . . . . . . : 06/29/2006
RECEIPT # . . . . . . . . . 35072
REFERENCE ID # . . . : 06060248
SITE ADDRESS . . . . . : 1128 STAFFORD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : DON FERRIE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : FRANK CARDIA
CONTRACTOR . . . . . . . : CARDIA, FRANK L LIC # 612
COMPANY . . . . . . . . . . : CUPERTINO PLUMBING
ADDRESS . . . . . . . . . . : 1300 DELL AVE, STE C
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 253-0618
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ---------- - - - ---------- ---------- ---------- -- - ------- ----------
BPGAS OULETS 1 . 00 5 . 40 0 . 00 5 . 40 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 .137 0 . 00 38 . 37 0 . 00
----- - ----- ---------- --------- - ----------
TOTAL PERMIT 43 . 77 0 . 00 43 . 77 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
-------------- --- ---------- -- ------------------
OTHER 43 . 77 MASTERCARD
TOTAL RECEIPT 43 . 77
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
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CITY OF CUPERTINO
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' M REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# � hI rl Date:
Building Address: G lJ J
11,28
Owner' ame: Phone#:
rFc— s 7--/S 90
Co ractor: Phone: License
Cont ct: U Phone: Cupertino Business License #:
/67c«t 4--
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Ei'--
Job Description: (` !fes �c 4' t
Residential 0—� Commercial ❑
Cost of Project:
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 Re i e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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