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07010057 CITY OF CUPERTINO BUILDING DIVISION ::PERMIT PERMIT NO. BUILDING ADDRESS: 22430 CUPERTINO RD TBDTOpER1vCIT ISSUE DATE OWNER'S NAME: 01/09/2007 GINA GAVIGLIO SANITARY NO. CONTROL NO. JNE: BUILDING PERMIT INFO ARCHiTECTIENGINEER: BLDG ELECT PLUMB MECH A O p LICENSED CONTRACTOR'S DECLARATION Job Description V 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing SEWER L::NE REPLACEMENT z with Section 70(10)of Division 3 of dtc Business and Professions Code,and my license is in full force andeftec tt__---- 1„�9p 7 CLEAR DRAIN PAID BL 1/9/07 j n z License Class [tDl1 •Z1`�s' Lie.i • 3[—in Date Contractor ARCHITECTS DECLARATION 12.i U 1 understand my plans shall be used as public records a L O y Licensed Professional n 0 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county K.1 ff which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement3 .Ft.Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $7000 Y=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Number Occupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3265002L . not more than five hundred dollars($500). ❑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 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 sa1.7 ❑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 docs not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec. B&P C for this reason Owner Date — 4 WORKER'S COMPENSATION DECLARATION 1 1 hereby affirm under penalty of perjury one of the following declarations: ❑I 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. ❑i 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 Wark/e1e,as,.Compens on insurance carrier and Polity number are:�� CarrierIt��br�('l'77.PoliryNo. Zr Jv CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Q (This section need not be completed if the permit is for one hundred dollars($100) /© 1 or less.) � (J 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 Workers Compensation provisions of the Labor Code,you must �`L forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY E.t►- I hereby affirm that there is a construction lending agency for the performance of p!> the work for which this permit is issued(See.3097,Civ.C.) Lq Q Lender's Name G. Lender's Address 1 certify that I have ad this application and state that the above information is U recorrect.I agree to comply with all city and county ordinances and state laws relating to Q V building construction, hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. >4 a (We)agree to save,indemnify and keep harmless the City of Cupertino against �CA 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-i: SOURCE REGULOQNS. ✓� r Re-roofs S' nature of Applicant/Contractor Dare T of hoof 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 19149 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 naterials for inspection. District? ❑Yes u 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safely 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"be At pn'44 to issuance of a Certificate of Occupancy. Signatui a of Applicant Date '� (Sr °, All roof coverings to be Class"B"or better wncr or authorized agent Date �. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ''UPEkTINO Building uildin De artment JOB ADDRESS: PERMIT # Z q3n v�t1/,e - d C a�oa #'7 OWNER'S NAME: �o < < Y�� , �, PHONE # �'��� 3s� - 37- GENERAL CONTRACTOR Lo-� FAX# I am not using any subcontracto , Si,nature Date Please check applicable subcontractors and com Clete 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 Owner/Contractor Signature Date CITY OF CUPERTINO 00D I DO 6-1 REPIPE/S _S/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN # 3�(0—50_CP) Date: D Building Address: r d Owner's Name: Phone#- qvo 2- Contractor: Phone: License#: ontact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb C Job escription. ms' s 62C ,fit'C,-y r -I,.L Residential Commercial ❑ Cost of Project• e .7:7 Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING BPGAS (Jas Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Repipe of Fixtures PLUMBING BPFIXTURE I'blg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING