05070148 (2) CITY OF CUPERTINO ia 1s 777'7�a,"s -�A+7^AW'A - -'� >>
BUILDING DIVISION PEIRMT d,,C0NT1AGT0R4NF0RMATI;OW
BUILDING ADDRESS: PLUMB—A—WAY PERMIT NO.0 5 070148
22460 N WALNUT rTR
ER'S NAME: PERMIT ISSUE DATE
BOR LYN —1653 -E CAPZTAC
ONE: SANITARY NO, CONTROL NO.
(408) 391-0930
ARCHOTCUE14GINEER: BUILDING PERMIT INFO
BLDGELER PLUMB MECH
= E I� 0
.0o LICENSED CONTRACTOR'S DECLARATION Job Description
rd 1 hemby of rm Ilial I am licensed under provisions of Chapter 9(commencing
with Sa:tion7g107of DiviaiOn3o(te Busimnaand Professions Code.andm license is
� is fall forte and eRe" 6 919 REPLACE 411 CAST IRON SEWER FROM HOUSE TO
51z_ License Clw - 3-6
Dem Contrcmanactor PROPERTY LINE.
�a^^-t
�i� IRECI'S OECLAR ION /
'CK I undo _my ply shall he u¢d blic menrds
yp0 Lice Professional
E IIDER DECLARATION
i 0 S I hemhy.(See .. 11. accept from ilio menttm,Co e:Any c law for the \
00 which au moon. emit t 71131.5,Business and Proimprove.
Ma on Crab:Any mity or county
$ which its i ma•permit Also re construct,altar,improve,demol4h,or repair any nructum
prior MetM s tabled,rsuantto Me pro vision nt offer sucCon permltm rile a,Law(Chapter
(cannot
wing
pursuanttoprovision of the Contractor's Liceruelaw(C om)or Sq.Ft.Floor Area aluatiotp900
3$ (commencing wit arefte70W)of Divkt&for the
euandon.myna Code)of
3
that he h eaempl Bem(mm and Oe baso for OIe alleged exemption.My vialatlon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Oce ane e
m
.at meM.five hundred dollars(g500). 35703049 . 00 p yTyp
❑1,u ownsr of tie property,m wagu my employees with e, their Arlo compensation,
will do the work.and the suacma 4 natimended oro@red ersate(Sm.IDN,Business Required Inspections
and profession.Cade:The Conmcames License Law dean not apply to a owner of q p
property who build.orimprote.tereon,andwhodoessuch work himself orthroogh his
awn employees,provided Met such improvements arc natimmraded mortemed fmaala.IL
however.the building or improvement is said within on year of completion,the owner-
builder will have die burdes of proving Most he did rot build or improve for pumom of
ale.).
❑1,as Owner of the properly,am exclusively contracting with licensed contractors to
constnmt the project(Se,.7044,Baines and Rofrators Code:)The Comsactofs Lt.
man Law darn not apply to an owner of property who Wilds or improver tames,And.
who contracts for such projects with a mounctor(0 licensed pursuant to M Commdota
License Law.
❑Iamaemptunder Sec ,BkPCfortismeson ...
Apr Dna
WORKERS COMPENSATION DECLARATION
1 hemhy affirm under penalty of perjury am of the following extaration:
❑1 haw and will maintain aCeNGauof Consent to sel5buum forWodmla Compcn.
sation,a provided for by Section 3700 of the labor Cade,for dm performance of the
work for which this permit is issued.
❑1 have and will maintain Work es Compensation Insurance,As required by Section
37M or the labor Cade,for the performance of the work fm which this permit is issued.
My Warkefs Compensation Insurance tarsier and Policy number am:
Cartier. . Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CThIs action need athecumpleted VIA,permit is Bureau hundred dollen(SIM)
or lax)
I certify that In the performance of the work for which this permit is issued.I shell not
employ any person in ay ma arnc�tb' t We ken'Campensa0on
Laws o(Celifomis.W
Applicant eat
NOTICE TOATPUCANTS r making this Cemncsu of Emulation,you should
become abject an the Worker's Compensation provision of the labor Cade,you must
., ,z forthwith comply with Such provision or this Permit that be canted revered.
zCONSTRUCnON LENDING AGENCY
h
F I hereby a affirm Met them los construction ten ding agencyfor tW perturmamc of the work(m which t4 permit is issued(Se,.7097,Co.C.)
aQ Lender's Name
.7. z Lender's Addrou
fJ Q I cenify that 1 have mad this application end tum tat the above inkannot an is
Comm I agree in comply with all city and coaly ordinances and sum laws misting in
0 building convection,and hereby authorize Mmetanmivcs of this city to enter upon Me
{37 above-men0aned property for Inspection purposes.
a (We)agree to arc.Indemnify and keep harmless the City of Cupertino aganst
liabilities,judgments,costs and expenses which may in any way amne against aid City
in
V APPLt ICA me oiL
B ERSTAmgo AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURSDate
GULAn
Re-roofs
Slgnuumof Ap antractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupat.mm or handle hoomms maudal
As defined by the Cupcmao Municipal Code.Chapter 9.13.ad the Health and Safely
FalS❑ Ip Na
Sessions
Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
call hanardaue air contaminants
.t�ap dcnwd by the Bay Am Air Quality Management all new materials for inspection.
0Ya
I have road to haardtasmautalstequimmcn x under Chepur6.95 of the Califor.
nia Healthk Safety Code,Seciimu 75505.35533 sea)25534.1 understand that time Wilding
Ones not currently h AN,that It 4 my responsibility to nod ly,the meupant of the
mquiremcnts wm met poor As issuance on C'mileam of Occup nature of Applicant Date
Own uthani'a ager, Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO
I 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 2
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35703049.00
DATE ISSUED. . . . . . . : 07/25/2005
RECEIPT #. . . . . . . . . : 30501
REFERENCE ID # . . . : 05070148
SITE ADDRESS . . . . . : 22460 N WALNUT CIR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BOR LYN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2740
RECEIVED FROM . . . . : PLUMB-A-WAY
CONTRACTOR . . . . . . . : CUONG NGUYEN LIC # 25129
COMPANY . . . . . . . . . . : PLUMB-A-WAY
ADDRESS . . . . . . . . . . : 1658 E CAPZTAC EXWY
CITY/STATE/ZIP . . . : SAN JOSE, CA 95121
• TELEPHONE . . . . . . . . : (408)391-0930
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 900.00 83.16 0.00 83.16 0.00
BENERGY PERMIT FEE 83.16 39.92 0.00 39.92 0.00
BPSEWER SEWER SYSTEM 1.00 21.58 0.00 21.58 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BUSLIC FLAT RATE 1.00 102.00 0.00 102.00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 285.03 0.00 285.03 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 285.03 1615
TOTAL RECEIPT 285.03
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ---__________=_____________=
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
•
acm
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
OUDCRT'A O Fax(408)777-3333
I�1 Building Department
JOB ADDRESS: PERMIT #
D.� &C) cv �N� 7 cue �� 0,5: 7vr
OWNER'S NAME: FCtZ- L PHONE # �►��- 96
GENERAL CONTRACTOR L UIM ( FAX #
I am not using any subcontractor 7�zs�l S—
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
Plumbing (�Lv�K ry wH y
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Z' mss'
er C actor Si Date
CITY OF CUPERTINO
•
a
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# — O3_ �-1 Date:
Building Address:
o c e� Llvu C,Zv2-
Owner's Name: Phone#:
Ot2L ti as a - 396 /
Contractor: Phone: License #:
E"'"
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
fZ_r- C+C_r e!', C +S7 7G l,/w - y
Residential Pr Commercial ❑
Cost of Project:
00
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping Sys ern Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING