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07020102 Ol! CITY CUPERTINO BUILDING DIVISION PERMIT � T �GQR Z (IRMTI�N PERMIT NO. BUILDING ADDRESS: 10219 JUDY AVENUE GOVIND TATACHAZI 07020102 PERMIT ISSUE DATE OWNER'S NAME: 02/21/2007 GOVIND TATACHAZI SANITARY NO. CONTROL NO. ,NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 p C LICENSED CONTRACTOR'S DECLARATION Job Description v I hereby affirm that I am licensed under provisions of Chapter 9(commencing (10)of Division 3 of the Business and Professions Code,and my license is Z with Section 70 SEWER LINE REPLACEMENT FROM CLEAN—OUT TO s y in full force and effect t z Lice Lie.x CLEAN ' ' "'1�c y Date � ARCHITECTS DELLA TION j C< understand pl�shall as public records NrI)aU . — W y License Professional a OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the n O 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 prior of its issuance,also requires the applicant for such permit to file a signed statementSq,Ft.Floor Area Valuation -Z a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $5690 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or L 5 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of A�64 not more than five hundred dollars(5500). 375070c-9 . V ❑I,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 docs 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 themon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec B&PC for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: hove and will maintain a Certificate of Consent to self-insure for Workees�Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of-the I work for which this permit is issued. 0 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 Worker's Compensaun Saw Ca carrier and Policy number are: G..;.fiAtAllrlE �Iw ^ficy No.:1023 C.05/Q. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE *�P(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 e 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY Fr rte•. I hereby affirm that them is a construction lending agency for the performance of (Y+> the work for which this permit is issued(Sec.3097,Civ.C.) A / i W A Lenders Name I 2 Lender's Address ^e U O I certify that I have read this application and state that the above information is V �+ �7 `2 (1. cored.I agree to comply with all city and county ordinances and state laws relating to fy G J 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 ,may 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--2 , �+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued l:y: SOUSE RE�G..UL�1 _ L 0 7 �� ,WE (k (l.�I&I Re-roof Signature of Applicant/Cantractor Dare Type of Roof HAZARDOUS MATERIALS DISCLOSURE yP Will the applicant or future building occupant stom or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All root s shall be inspected prior to any roofing material being installed. ❑Yes i'° If a roo r 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 materials for inspection. District? ❑Yes BA. 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building does not currently have a tenant.that it is my responsibility to notify the occupant of the Date requirements which must met prior to issuance of a Certificate of OcSu n Signature of Applicant All roof coverings to be Class"B"or better Own or authorized agent Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: amyw COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 3-/507059 . 00 DATE ISSUED. . . . . . . : 02 /21/2007 RECEIPT #. . . . . . . . . . BE000000496 REFERENCE ID # . . . : 0;020102 SITE ADDRESS . . . 1(219 JUDY AVENUE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER GOVIND TATACHAZI ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : RE:CEIPT INTERFACE CONTRACTOR LIC # *OWNER* COMPANY GOVIND TATACHAZI ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT 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 ----------------- --------------- -------------------- CREDIT CARD 166. 95 VISA --------------- TOTAL RECEIPT 166 .95 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ----------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 507 FINAL PLUMBING Community Development 10300 Torre Avenue {. Cupertino CA 95014 Telephone(408)777-3228 'CITY OF Fax(408)777-3333 -UPEkTINO Buildin De artment JOB ADDRESS: PE�ZMIT # L02a at Jv o y %J OWNER'S NAME-60 VIAD PHONE #1017 .29Z 702-(6 GENERAL CONTRACTOR: R ori r FAX# I am not using any subcontractors: PC — Signature Date Please check applicable subcontractors and complete the followin 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 Sheet Rock Tile C:a � � ��J2� 10-1 Owner/Contractor Signature Date CITY OF CUPERTINO 010201 M REPIPE/S WEELS/MAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN# 3-1 5 —lJ..l"1 Date: J 10-7 Building Address: 102101 JUDY %Ue- Owner's Nam Phone#: L405' 20 G - 16 SS Contractor Phone: License#: Gv6-v (Zo oter X96 9461 -712,054 Contact: Se6kt 4Phone4C'Irs0Cupertino Business License#: �,�{X01 Building Permit Info: Bldg ❑ Elect ❑ Plumb Job Description: Se �- ^1`rVw�- �l ^�J + L�ec.n_a v rwar �in•� �P��G� Residential X Commercial ❑ Cost of Project: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE 31dg. Permit Fees BUILDING BPGAS Sas Pipin System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Pepipe of Fixtures PLUMBING BPFIXTURE Pblg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING ' BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING