07020050 777777777777777777777
CITY OF CUPERTINO
BUILDING'DIVISION PERMIT � IL�CjQR I�CRMATI€Il�'
BUILDING RE PERMIT NO.
2141r TAI AV JOHN& `4ARGARET STUBBELB INE 0 7020050
OWNER'S NAME:
PERMIT ISSUE DATE
JOHN & MARGARET STUBBELBINE 21491 VkI AVE 02/08/2007
IE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGiNEER: BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
w I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPAIR kP PROX I MATELY 2 0 FT OF SEWER OUTSIDE OF
R!
in full force and eCt t,
RnLicense Class Lice FOUNDATION, INSTALL PROPERTY LINE CLEANOUT.
t p Datc Contraclor
a ARCHITECTS DEC RA N
I understand my plans shall be used as public records F^A��G G
DWUa
Z o H Licensed Professional
cal-3 OWNER-BUILDER DECLARATION
e f I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
K f4L which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $4000
43
y .. 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). 36205021 . V V
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure isnot intended oroffered forsale(Sec.7044.Business Required Inspections
Professions Code:The Contractor's License Law dans not apply to in owner of
:rty who builds or improves thereon,and who does such work himself or through his
n 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.).
❑I,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 docs 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 Contractors
License Law.
❑lam exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby amrm under penalty of perjury one of the following declarations:
U I have and will maintain a Certificate of Conscnt 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.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy- a �
Carrier. Policy No. �✓ ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
less.)
oily 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
,J,Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(ter►C4.+ I hereby affirm that there is a construction lending agency for the performance of
Ix> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
CL� Z Lenders Address
V I certify th 1 ve read this application and state that the above information is
[1r cosec'.1 agree to o ply with Zcoun county Ina ccs and sate laws relating to
Ubuilding conswc o ,and herebe repre mai es of this city to enter upon the
above-mentione p perty for inpurpo s.(We)ag to save,indeke h less the City of Cupertino against
to liabil'' ,jud9 nts,costs and 'h in any way accrue against said City
U Z in c quen f the granting ort.APP ICA NDERSTANDI COMPLY WITH ALL NON-POINT Issued by Date
SO C E ULATIONS� Re-roofs
Si Vill
ApplicanUCon for Date
H DOU MA LS DISCLOSURE Type of Roof
the applicant or future buildin cupant store or handle hazardous material
as defined by the Cupertino Municipal dc,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)v All roofs ihall be inspected prior to any roofing material being installed.
❑Yes to
Will the app c t or future building occupant use equipment or devices which If a roof i installed without first obtaining an inspection,I agree to remove
.it hazardous air o minants as d frncd by the Bay 'Air Quality Management all new materials for inspection.
District?
❑Ycs Nu
1 have re the hazardous materials require under Chapter 6.95 of the Califor-
nia Heal
.V;
S Code,Sections 25505,2553 534.1 understand that if the building
does no cu d have a tenant,that i is m risibility to notify the occupant of the
require c wh h must be met psi to' u ce of a Certificate of Occupancy.
o Signature of Applicant Date
All roof coverings to be Class"B"or better
w-A�Rorizcd agent Dater
.' `,fi Community Development
10300 Torre Avenue
; ' ` Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
`-UPEkTINO
Building Department
JOB ADDRESS: r PERMIT #
Z1A v O 77 2 0 0 -r �
OWNER'S NAME: #j -- a'S3 N` P ONE # 34
—
GENERAL CONTRACTOR
I am not using any subcontractors: r a 2 -u8 -o7
Si gn Date
Please check applicable subcontractors d complete the foll/wing information:
SUBCONTRACTOR BUSI14ESS 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
S e Rock
T4e/
/--j- /-Z
er/C ntr ct Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIP RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Bl,,: Lot:
APN . . . . . . . . . 36205021. 00
DATE ISSUED. . . . . . . : 02 /08/2007
RECEIPT #. . . . . . . . . : BSDO0000424
REFERENCE ID # . . . : 07 )20050
SITE ADDRESS . . . . . : 21191 VAI AV
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : J0:3N & MARGARET STUBBELBINE
ADDRESS . . . . . . . . . . : 21-191 VAI AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : JOHN & MARGARET STUBBELBINE
ADDRESS . . . . . . . . . . . 21-191 VAI AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY ;MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
BPSEWER SEWER SYSTEM 1. 00 21 .58 0. 00 21 .58 0. 00
BUSLIC FLAT RATE 1. 00 107 .00 0. 00 107 .00 0. 00
PPERMITFEE FLAT RATE 1. 00 38 .37 0. 00 38 .37 0. 00
----------- ---------- ---------- ----------
TOTAL PERMIT 166 .95 0. 00 166 .95 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 166 . 95 535
---------------
TOTAL RECEIPT 166 .95
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
CITY OF CUPERTINO
1 REPIPE/SERV �,-S/M.AIN SERVICE
CUPE(�TiNO PERMIT APPLICATION FORM
APN # � tet— ate:
Building Address:
2 `4 U
Owner's NaLa Phone#:
Contractor: hone: License#:
C, -s KU(-91A/ 6 G(
Contact: , Phone: Cupertino Business License#:
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Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Tob Descriptio `
2C
Residential Commercial ❑ -F aU ,J O -F;T, LtdJY
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE E-ld . Permit Fees BUILDING
BPGAS Cas Piping System Fee PLUMBING
J PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE R:epi e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS main Water Service PLUMBING
J BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC E usiness License BUILDING