04050097 (2) CITY OF CUPERTINO v k d I
BUILDING DIVISION PERMIT
CON�'.CRATQR,INk'U12�vI'ATror
BUILDING ADDRESS: PERMIT`b4050097 b4050097
ii sTAPPRon
OWNER'S NAME: PERMIT ISSUE DATE
KARAPP
iONE: SANITARY NO. CONTROL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y mO p LICENSED CONTRACTOR'S DECLARATION
as 1 hereby affirm that I am licensed under previsions of Chapter 9(commencing Job Description
with Sectign 7010)of Division 3 of be Be3fagvx eBi Professios nCode,and my license is
^�d in tall f.00ac .gyp t REPAIR SEWER ON PRIVATE PROPERTY
z�� ease Class LiC.N _
e -oar c°"'rte ON CONTRACTOR: STREAMLINE PLUMBING INC.
A CHITECTS D
INm 1 understand my plana shall be used as public records
ion' Licensed Professional
g - OWNER-BUILDER DECLARATION
<I 1 hereby affirm
that 1 am exempt from the Contractor's License Law for the
GO following reason.(Section 7031.5,Business and Professions Code:Any city or county -
which requires a pmmit to construct.altar.imp-w,do millsh.or repair any structure
FZ prior to its issuance,also requires the applicant for such permit o flit a signed summer.
G that he is licensed pursuant to the Previsions of the Connector's License Law(Chapter 9 Sq.Ft.Floor Area Valua"g89
$ (commencing with Section 70(10)of Division 3 of the Business and Professions Code)or
,at he it exempt therefrom and the basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit schisms the applicant o a civil Penalty of APN Number Occupancy e
not more than five hundred doll.(&500). 36111031 . 00 P Y EYP
❑I'm owner ohhe property,or my employees Mith wages as their sole compensation.
willdo the work.and the swetum Is nolin eaded aroRmed(mail.(Sec.7044,Business
and Pheromones Cade:The Commicu s License law does not apply in an owner of Required Inspections
property improvements;
anessuchwork himselforNrough his
ownemployees,lding and Cmauchempreold stere not antiffined forthe owner.
builder
however,the have
the
ar impre Movieis hath within ane uld ofcrmole far the ownsr-
$.InI Twill have Ne burden of provin6 that he did not bulla or improv for puryose of
ailed.
❑r,asa owner of the properly,.Bexclusivelysiend contracting with licensed canhamam t. / Y
come Lawct d es not appl(Secy
to an Business and property
who
Code:)Them thecon. Li.
acme law does not apply m es owner of properly who build¢or Witham Centra,and C
who commas for each pmjecu with a cantracmr(q licensed pursuant to the Contractor's C '
Clams Law. 7
❑lam exempt under sec. ,B&.PCfor this moon
137M
wner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of periery one of Ne following declarations:
1 have,and will maintain a Certificate ofConxeen to self inure for Workefs Crimper.
tion,u provided for by Section 3700 of the labor Code,for the performance of the
rk for which this permit is issued.
ff 1 have and will maintain Worker's Compensation Insurance,as required by Sechon
of Ce Labor Code,for Ce performance of the work forwhich Nis permit is issued.
y Workms CL��Compensation Inaunnce certicr and Pa> un r dmf �
'er 'FERMT"' policy
WOR E
CERTIFIC OMPE EXEMPTION WORKERS'
COMPENSATION INSURANCE
(This sec0an need not becompl.edifrhe permit is baroachundreddollam(SIM)
or less)
I certify that in to offmc mem of ban work for which this Permit is issued.I shall out
employ any person in any manners"as to become subject to the Workers Compcmadon
Law,of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Campeau,of Exemption.you should
become subject in the Workers Compensation provisions or the Lehr Code,you must
.Jz frMwith comply with such provisions or this permit shall M doomed molted.
,'Z., O CONSTRUCTION LENDING AGENCY '
(rte I hereby affirm thus Cerc is a construction lending agency far the perfunnarm of
ai the work for which Cu permit is issued(Sm:.3097,Civ.C.)
{27 Q Lender's Namc
z, Lcnaer's Address
U Q I certify that 1 have mad his application and state Nat Ne shove information is
{[v F comer..I agree to comply with all city and county rNinan es and sure laws totaling m
O V building conswetion.ens ercby emhodae rcprcsentalires of Ni¢city mentor upon Cc
07 above-n,judgm ropers and A
ctiopurpohich ms.
LL (We)as. o save imeMop homeless the City of Cupertino againal `
y inconsesence,o ,cos intlhich mey In eny way seems egainssaud City(„)z in consequncc of c gra ing ss.APPLICANT UN ERS NDILL COMPLY WITH ALL NON-POINT slued by:S4�� az Date
U CE REGU
Re-roofs
' ignamrc a pylic ARD US MA IALS DISCLOSURE Data Type of Roof
Will the applicant or cusum building occupant$mrc or handl.havardous material
az defined by tho Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
ode,Section 25332(a)? All roofs shall be inspected prior to an roofing material being Filmsh . r P P Y S g installed.
Will the applicant or future building occupant use equipment or devises which If a r0 f is i stall d without first obtaining an inspection,I agree to remove
mit ha.amous air contaminants as defined by the Bay Area Air Quality Management all ne ma rials for inspection.
Diavict1 / P
❑ 5 ❑N
Its mad eMxaNams mamrialsmyviremcns under Chapter 6.95 aflha Calif., (�Q�
ma Hcallh Safety .do,Scdom MS05,25533md75534.lundemWdthairth.Wilding
docsnotcu My
w a tenant That it is my responsibility m nobly the acupans of the
requl uwbaanm prior In issuance of a Cardcam of Oce cX igna Of pl icant Date
own d as. 'm-)- All roof coverings to be Class "B" or better
Community Development
aC10F
10300Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
� Fax(408)777-3333 UPEI�TINO
Building Department
JOB ADDRE�W py"IT#
(�1( ST4FX-a,�4.44 ol OS ov 9?
OWNER'S N C PHONE 7Ft ,7SS
GENERAL CONTRACTOR 1( ftamBtPI=6 FAX # 47 . /pq
I am not using any subcontractors:
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
Plastering
PlumbingSTC
Roofing
Septic Tank
Sheet Metal
Shept c
Am I Til
Date
/Contractor Signature
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# Date: fl
Building Address:
Owner's Name: Phon
e
Contract o Phone: XtD / Le#:
✓vc '7?-Z;go C-18
Contact: Phone: Cupertino Business License#:
clekb
Building Permit Info: , /
BldgEl Elect El Plumb LN'
Job Description:
0A) D4.e1(/o4Z�-l�o4Pe
Residential omm rcial ❑
Cost of Project:
4�9.oa
•
Qtv. if
A ale Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
zs�.r�
i
CITY OF CUPERTINO
` r
m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36111031 . 00
DATE ISSUED. . . . . . . : 05/17/2004
RECEIPT # . . . . . . . . . : 25558
REFERENCE ID # . . . : 04050097
SITE ADDRESS . . . . . : 1211 STAFFROD RD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . :
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : KARAPPANCHETTY PALANIAPPAN
ADDRESS . . . . . . . . . . : 1211 STAFFROD RD
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : STREAMLINE INC
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
- / EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 3 , 989 . 00 97 . 00 0 . 00 97 . 00 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 19 . 98 0 . 00 19 . 98 0 . 00
PPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
---------- ---------- ---------- ----- -----
TOTAL PERMIT 252 . 50 0 . 00 252 . 50 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 252 . 50 16010
TOTAL RECEIPT 252 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING