07020121 CITY OF CUPERTINO
'BUILDING;DIVISION PERMITNP}RMTIE�N�
BUIL 1 KESS: PERMIT NO.
�� REGNART RD PLUMBEF S ON CALL 07020121
OWNER'S NAME: PERMIT ISSUE DATE
VINCENT & WENDY WIN 520 MEGLIACY LANE #12 02/26/2007
SNE:
SANITARY NO. CONTROL NO.
(408) 8','9-9416
ARCHITECT/ENGINEER: BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
!0 C LICENSED CONTRACTOR'S DECLARATION Job Description
U p 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
.Zui with Section 7000)of Division3oftheBusinessandProfessionsCode,andmylicenseis REPLACE: FRESH WATER PIPES/COPPER NO VALVES
?'H infoal force and effec / � (7/7�%y� _
i ? License Cl a Lic.N
t- Date Contradar raW:s!
ARCHITECTS DECLARATION
i < I understand my plans shall be used as public records
)qU
'
U.N Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
C C O following reason.(Section 7031.5,Business and Professions Code:Any city or county
$�i. which requires a permit to construct,alter,improve,demolish,or repair any structure
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or $9200
L that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars(5500). 3562404:2 . 17U
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
Q 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's/Compensation I urance c_a/ricr and Policy number are:
Cartier. Sl�c� 7GY Policy No.: aeZ/7L -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
F. rA 1 hereby affirm that there is a construction lending agency for the performance of
(Y> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name --
2 Lender's Address
U 0 1 certify that L have read this application and state that the above information is
w ►-' COMCCL I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction.and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
CY (We)agree to save•indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
►- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b
SOURCE REGULAT199�S.
_a� - Re-roof:
Signature of Applicant/Conuactor Date T of Zoof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roof:;shall be inspected prior to any roofing material being installed.
❑Yes 2-WO
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new 1 naterials for inspection.
District?
❑Yes 2'Fu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met poor issuance of a Certificate of Oce�aner. Signatur,of Applicant Date
All roof coverings to be Class "B"or better
Owner or authorized agent Date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 3E624042 . 00
DATE ISSUED. . . . . . . : 02/26/2007
RECEIPT #. . . . . . . . . BE000000530
REFERENCE ID # . - - : 07020121
SITE ADDRESS . . . . . : 21715 REGNART RD
SUBDIVISION . . . . . .
CITY CL PERTINO
IMPACT AREA . . . . . .
OWNER VINCENT & WENDY WIN
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4820
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : RC,BIE DOBKINS LIC # 27158
COMPANY PLUMBERS ON CALL
ADDRESS 520 MEGLIACY LANE #12
CITY/STATE/ZIP . . . : C.7.MPBELL, CA 95008
TELEPHONE . . . . . . . . : (908) 879-9416
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
BPREPIPE NO OF FIXTURE 11.00 99.00 0 .00 99. 00 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
- --------- ---------- ---------- ----------
TOTAL PERMIT 137.37 0 .00 137 .37 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 137.37 14575
---------------
TOTAL RECEIPT 137.37
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
CITY OF CUPERTINO
CIF
REPIPE/S WE� MAIN SERVICE
CUP ,6ING PERMIT APPLICATION FORM
APN# 5 Date:
Building Address:
Owner's Name: Phone#:
(..one
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
ET-
Job Description: /
ax- I PS ;-1-7 ��irLL-C
Residential E�- Commercial ❑
Cost of Project:
97/ 2 6�
11
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 Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING