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07080265 .77777777777777 CITY OF CUPERTINO UILDING,DIVISION PERMIT C�NTI:AGTCIR IJYFO MATIQN. B BUILDING ADDRESS: PERMIT NO. 10290 JOHNSON AVE SUPERIOR PLUMBING 07080265 OWNER'S NAME: PERMIT ISSUE DATE LUCAS SOYENSKI 189 BENDER CIRCLE 08/30/2007 +ONE: SANITARY NO. CONTROL NO- (408) 528-4103 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 p o LICENSED CONTRACTOR'S DECLARATION Job Description U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 7000)of Division 3 of the Business and Professions Code,and my license's REPLACE, SEWER LINE in in full force and effect M? License Class Lia S F Date Contractor ARCHITECTS DECLARATION a 1 understand my plans shall he used as public records LU V0.V C H Licensed Professional OWNER-BUILDER DECLARATION 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 m 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 H (commencing with Section 7000)of Division 3 of the Business and Professions Coe)or $3000 Code) 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 ofNumber Occupancy Type not more than five hundred dollars(SSW). 375250_37 .W ❑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 Cade:The Contractor's License Law does not apply to an owner of q P 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- bugder will ave the burden of proving that he did not build or improve for purpose of as mer of the property,am exclusively contracting with licensed contractors to const as t 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 su h projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt and Sec. B&P f tkis rea�on .� Owner Date 3� 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- .ation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. C3 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 Compensation insurance carrier and Policy number are: Cartier: Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section recd not completed if the permit is for one hundred dollars($100) or less.) I certify that in the perforkeec work for which this permit is issued,I shall not employ any person in any 1 to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:Waftcr 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. N O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of >!i> the work for which this permit is issued(Sec.3097,Civ.C.) C7 A Lender's Name z Lender's Address 0 I certify that 1 have read this application and state that the above information is ►+ correct.I agree to comply with all city and county ordinances and state laws relating to D V building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. " (We) me to save,indemnify and keep harmless the City of Cupertino against y liabilities,jud mens,costs and expenses which may in any way accrue against said City Z in consequent of the granting of this permit. Date APPLICANT NT AND WILL COMPLY WITH AL N N-PO ssued t y: SOURC LATIONS. R,� �V Re-roof; Signature A plicant/Contraetor Date HAZARDOUS MATERIALS DISCLOSURE Type,Of Roof Will the applicant or future building occupant store or handle hazardous material as deftned by the Cupar o M nicipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a) All roofs shall be inspected prior to any roofing material being installed. ❑YesNo Will the applicant or future building occupant use equipment or devices which If a root'is installed without first obtaining an inspection,I agree to remove :mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes / ❑1� I have ad the hazardous materials requirements undcrChapter 6.95 of the Califor- nia Health&S c ode.Sections 25505.25533 and 25534.1 undcrs d that if the building does not cu have a tenant,that it is my responsibility to d the occ ant of tty, rcyuircmc w n the et prior to issuance of a Ccni pan •6 Signatu:e of Applicant Date owmer or a o .cd agent Dam _ All roof coverings to be Class"B"or better CITY OF CUPERTINO 2 ITEMS OF 3 PERMIT RECEIPT OPERATOR: bethe COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot: APN . . . . . . . . : 37525057.00 DATE ISSUED. . . . . . . : 08/30/2007 RECEIPT #. . . . . . . . . : BS000002522 REFERENCE ID # . . . : 07080265 SITE ADDRESS . . . . . : 10290 JOHNSON AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LUCAS SOYENSKI ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : LUKAS SLAWINSKI CONTRACTOR . . . . . . . : ERABMO SOTO-CHACON LIC # 26939 COMPANY . . . . . . . . . . : SUPERIOR PLUMBING ADDRESS . . . . . . . . . . : 189 BENDER CIRCLE CITY/STATE/ZIP . . . : MOR37AN HILL, CA 95037 TELEPHONE . . . . . . . . : (403) 528-4103 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 PPERMITFEE FLAT RATE 1. 00 40.79 0 .00 40 .79 0. 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 62 .37 0 . 00 62 .37 0. 00 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 CUPEkTINO Building Department JOB ADDRESS: CSU P. PERMIT # tOZ.1Cl) �C�la�tg pAJ �S"o CT? 6e&z-6s OWNER'S NAME: Z f264 cv l ou 5 tc PHONE # ,qo,? — 7 t 6 GENERAL CONTRACTOR::50 1 vie FAX # PG cwt ,6lA- G I am not using any subcontractors: Signature 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 Tank Sheet Metal Sheet Rogk Tile r-l� - J� er Contractor Signature Date CITY OF CUPERTINO REPIPE/ E W -Z.-S/FAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM D-7o$oa65 APN# Dater Building Address: 102 ,90 q-O Owner's Name: 2 Phone b p Contracto- Phone: License 2 Cpn�c Z Phone: uperti usiness Lie se#. <Fyj.,� Building Permit Info: / Bldg ElElect ElPlumb LAY Job Description: Residential ❑ •G l�Coommercial ❑ Cost of Project: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING BPGAS Gras Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPFIXTURE Pblg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Eusiness License BUILDING