07010143 CITY®F CUPERTI1�10 PERMIT
BUILDING'DIVISIOPa G�1�TR��G�I'I'iR I1FC}RMTI�l�,
PERMIT NO.
BUILDING ADDRESS:
OWNER'S NAME:
MARY PALMER 656 N K::NG RD 01/23/2007
SANITARY NO. CONTROL NO.
.ONE:
(408) 251-6040
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
a a 0 0
5 p C LICENSED CONTRACTOR'S DECLARATION Job Description
V
P 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
e-Z E6 with Section 7000)of Division 3 of die Business and Professions
Co n license is SEWER L C NE REPLACEMENT LATERAL UP TO SIDEWALK
y in full force and effect C 5 Lic.>r 1O0pp v ALLSTAR PLUMBING RENEWED BL 1/23/07
DM Z License Class s
=o- 2r
Da1C Off ft'i C') Contracto
.J CTS DECLARATION
a-4 1 understand my plans shall be used as public records
9L
u.
u.H Licensed Professional
n y OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
`E p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
$Pi which requires a permit to construct.alter,improve,demolish,or repair any structure
"rn prior to its issuance.also requires the applicant for such permit to file a signed statement Sq,Ft,Floor Area Valuation
?< that he is licensed pursuant to the provisions oC the Contractor's License Law(Chapter 9 $4000
Yo-=-$ (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 Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6 2 0 2 014 .`�1�,p�`lf'Number
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their soic 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.).
❑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.
❑I 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:
❑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 Workers Compensation Insurance,as required by Section
SANI
3700 of the Labor Code,for the performance of the work for which this permit is issued.
TARY
My Workers Compe"on Insurance carrier and Policy number
ber are: ed
Cartier. 1.�x(t� r 1Nt(t AkgoPolicyNo.: -f 4-1--t.-6_,
CE IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars(5100)
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
py the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
2 z Lender's Address
U C I certify that I have read this application and state that the above information is
I>. correct.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
above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS. —:
1
so Re-roof,;.
Signature of Applicant/Con r Dao T of Roof
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
Cote,Section 25532(a)? All roof shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or uturc building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as dcftncd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
(have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if the building
does not c mly have a tenant,that it is my responsibility to notify the occupant of the Date
requircme which must be met prior to issuance of a Certificate of Occup cy. Signatu.'e of Applicant
112-51+� All roof coverings to be Class"B"or better
Owner or uthorircd agent Date
Community Development
10300 Torre Avenue
y
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
''UPEkTINO
Buildi n Dt
e arment
JOB ADDRESS: PERMIT #
�- -7ararY3
OWNER'S NAME: au' Pit , ,r- PHONE # k o�
GENERAL CONTRACTOR: ,A�(S p�.�o, t FAX #
I am not using any subcontractors;
ISO—
__(),S�i:,nature Date
Please check applicable subcontractors and coml)lete the followin info:IZ:Ermation:
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 Qr7o 1 014 3
'vREPIPE/S a �
' . .S/MAIN SERVICE
CUPEt�TINO PERMIT APPLICATION FORM
APN # Date:
f 2 `�, �a`"T
Building Address: 21 LA O ,\
Phone#:
Owner's Name: �, n
t"�C�.1 �-�� �a�amu-- �o � Z y z
Coraptor* Phone: License#:
�1 S� .,,, 3 i 1 civ S
Contact: Phone: Cupertino Business License#:
\- 0J-"-1k �g 23o SSG 2-2,1
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential P Commercial ❑
Cost of Project:
Qty. if
Applicable— Fee ID Fee Description Fee Group
ER
MFEE 131dg. Permit Fees BUILDING
BP
BPER Jas Piping System Fee PLUMBING
PPERMITFEE Numbing Permit Issuance PLUMBING
BPREPIl'E :
JAN-29-2007 15:23 MARK THOMAS CUP
4082535173 P.01i01
SIX I MAP,
DISTRICT MANAGER-ENGINEER
S ®/, BOARD OF DIRECTORS
MARK THOMAS&COMPANY,INC. y� ! STEPHEN C.ANDREWS
DAVID E.R055 WILLIAM A.BOSWORTH
'
YIAZ3 }F JOHN M.GATTO
DISTRICT COUNSEL SF.:QVI E �� CURTIS B.HARRISON
ATKINSON•FARASYN,I-I,P, .PrW&A is so
~� WENDELL H.KERR,JR.
HAROLD 5.TOPPEL
20833 STEVENS CREEK BOULEVARD,SUITE 1104
CUPERTINO,CALIFORNIA 95014,2154
(408)2E&7071 PHONE • (408)2S3-5173 FAX
www.cup ertinosanitarydistrict.com
File: CuSD—MOP
Building Dept. —Cupertino
City of Cupertino
Attn.: Building Department
10300 Torre Ave.
Cupertino, CA 95014-3202
Subject: Sewer Line Replacement
Name; Mary Palmer
Address: 21445 Holly Oak Dr
APN: 362-02-014
Permit No.07010143
■ Videotape and Property Linc Cleanout inspected.
No additional conditions/requirements by the District.
1;
Inspector: George Santos .................................... .. :
P
Date:...01-29-2007................... Sanitary Sewer Location:
5'Deep
30' Long
cc: Property Owner
*Backflow Device Inspected.
SUPPLYING SANITARY SEWERAGE SERVICES FOR:CITY OF CUPEF:TINO,PORTIONS OF THE CITIES OF SARATOGA,SUNNYVALE,LOS ALTOS AND
SURROUNDIN[UNINCORPORATED AREAS
TOTAL P.01