07010086 CITY-OF CUPERTINO
BUILDING DIVISION PERMIT NNW
PERMIT NO.
BUILDING ADDRESS:
27 CLIFDEN WY CUPERTTr
PERMIT LSSUE DATE
OWNER'S NAME:
RON PAGET 1300 DELL AVE, STE C 01/16/2007
SANITARY NO. CONTROL NO.
)NE:
(408) 25] -0618
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION Job Description
t VP I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is WATER M t I N CHANGE
11"40. m fullforec and effe t
? License Class _ Lie.8
9 t- Date — Conlraaor �� C
,a ARCHrTECTs DECLARATI N
Cz-<1
I understand my plans shall be used as public records
a
iC H Licensed Professional
n y
OWNER-BUILDER DECLARATION
<2 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,alter,improve,demolish,or repair any structure
Z; prior to its issuance,also requires the applicant for such permit to file a signed statement .Ft.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $1500
xF= (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
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3693700,;
.)W Number Occupancy Type
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
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-
ccnse Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such pmjects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
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 Wor ompensatiory Insurance carrier and Policy number are:
Carrier. I't Policy No.:-,2 1 2 V D• 3�12i
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,alter 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 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
(x 7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
]Z Lcndees Address
V C) I certify that I have read this application and state that the above information is
VZ H correct I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
►F-r t2 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 N AND WI COMPLY WITH ALL NON-POINT Issued by:
GULA
Re-roofs
Signature pplt/Ca or Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino �N_
cipal C Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yeso
If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
:mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes e t�
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
acs not currcn a naw, at it is my responsibility to notify the occupant of the
which must prio i cco(aCcrtificaLeofOccupan Signature of Applicant Date
�G Wil] All roof coverings to be Class"B"or better
Owner of iuthori agent Date'
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36937003 . 00
DATE ISSUED. . . . . . . : 01/16/2007
RECEIPT #. . . . . . . . . : BS030000220
REFERENCE ID # 07010086
SITE ADDRESS 20327 CLIFDEN WY
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER RON PAGET
ADDRESS
CITY/STATE/ZIP . . . : CUFERTINO CA, 95014-4460
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : CAFDIA, FRANK L LIC # 612
COMPANY . . . . . . . . . . : CUFERTINO PLUMBING
ADDRESS . . . . . . . . . . : 13CO DELL AVE, STE C
CITY/STATE/ZIP . . . : CAYPBELL, CA 95008
TELEPHONE . . . . . . . . : (4C8) 253-0618
I
FEE ID UNIT QUANTITY 1,MOUNT PD-TO-DT THIS REC NEW BAL
-- ------ ---------- -
BPWSVCS WATER SERVICE 1. 00 9 .00 0. 00 9 .00 0. 00
BSEISMICRE VALUATION 1, 500. 00 0.50 0. 00 0.50 0. 00
PPERMITFEE FLAT RATE 1. 00 38.37 0. 00 ----- - ------ -- --
TOTAL PERMIT
------ ------
------0. 00 47 .87 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ---------
CREDIT CARD 47 . 87 VISA
---------------
TOTAL RECEIPT 47 . 87
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------
_____
----------------------------
103 UFER 106 SEWER & WATER
507 FINAL PLUMBING
• Community Development
10300 Torre Avenue
'{ Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
`WEkTINO
Building Department
JOB ADDRESS: cv,fctet) )�3q PERMIT #
OWNER'S NAME: ?Xn `P61 A- • PHONE # 4C6'25 S-c(OI fg
GENERAL CONTRACTOR: 'no b� %FAX #
710
1 am not using any subcontractors:
ignature 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
Roofing
Septic T
Sheet etal
S et Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
REPIPE/SE E.VS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # :
Date
Vol" 3-1_ V_ 3 �
Building Address:
Owner's Phone#:
Pqntractor: (� Phone: t 3^ License #:
C ntact. Phone: Cupertino Business License#:
C
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑��f
Job Description: [A 4-) (--\
Residential Commercial ❑
Cost of Project,;%
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 11blg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC 13usiness License BUILDING