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07090023 CITY OF CUPERTINO BUILDING-DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 10604 LA RODA DR PLUMBER ON CALL 07090023 PERMIT ISSUE DATE OWNER'S NAME: ANDREWS GENEVIEVE A 520 E MCGLINCY LN 09/07/2007 AE: SANITARY NO. CONTROL NO. (408) 8i9-0483 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH 0 t p p LICENSED CONTRACTOR'S DECLARATION Job Description V1- I hereby affirm that I am licensed under provisions of Chapter 9(commencing z UW with Section 7000)of Division 3 of the Business and Professions Code,and my license is RE P I PE TO COPPER AND ADD WATER HEATER. =y in full force and effect. v�z License Lam•F f w Date Contractor ARCHITECTS DECLARATION i a< I understand my plans shall be used as public records :0.0 n.t-- Licensed Professional y_< OWNER-BUILDER DECLARATION > 1 hereby affirm that I am exempt from the Contractor's License Law for the 3 p 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 strtreture Z y prior to its issuance,also requires the applicant for such permit to file a signed statement r, Valuation x< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ,,q.Ft.Floor Area $6675 G(- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or rthat 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 of Number Occupancy Type not more than five hundred dollars(5500). 3 6 9 3 3 01 E 0 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 does not apply to an canter 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.). 0 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractors 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 Contractors License Law. 0 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: 0 1 have and will maintain a Certificate of Consent to self-insum for Workers Compen- sation,as provided for by Section 3700 of the Labor Code•for the performance of the work for which this permit is issued. C34 have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation In urance mer and Policy number are: Carrier.(<;r �.101-r Policy No.: 64.212 G5' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) 1 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 F~-r r•Cn-i -1 hereby affirm that there is a construction lending agency for the performance of _ ai> the work for which this permit is issued(Sec.3097,Civ.C.) W C) Lendcr's Name 0 z Lender's Address U 0 I certify that 1 have read this application and state that the above information is LI t correct.1 agree to comply with all city and county ordinances and state laws relating to Q U building construction.and hereby authorise representatives of this city to enter upon the a above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against ,-q rJI liabilities,judgments•costs and expenses which may in any way accrue against said City U 2 in consequence of the granting of this permit. Date �^ Z �+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE jFyGULATIONS`.�„ S "7/;;;/"7_ Re-roofs Signature of ApplicantIConuactor Date T Of RJof 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 roofs:;hall be inspected prior to any roofing material being installed. 0 Yes C3 No Will the applicant or future building occupant use equipment or devices which If a roof i:;installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m iterials for inspection. District? D Yes 0 1 have read the hazardous materials requirements under Chapter 6.95 of tiro Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if ttrc building docs not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must bemetmet prior of a Certificate of Ocegppgcy1Signature of Applicant Date 'T Y��/�1!� All roof coverings to be Class"B"or better Owner or authorized agent Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk.: Lot: APN 36533018.00 DATE ISSUED. . . . . . . : 09/ 07/2007 RECEIPT #. . . . . . . . . : BS( 00002572 REFERENCE ID # . . . : 07( 90023 SITE ADDRESS . . . . . : 10( 04 LA RODA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : ANDREWS GENEVIEVE A ADDRESS . . . . . . . . . . : 10604 LA RODA DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4416 RECEIVED FROM . . . . : PLUMBERS ON CALL CONTRACTOR . . . . . . . : ROBIE DOBKINS LIC # 27158 COMPANY . . . . . . . . . . : PLUMBERS ON CALL ADDRESS . . . . . . . . . . : 520 E MCGLINCY LN CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 879-0483 FEE ID UNIT QUANTITY !iMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- BENERGY PERMIT FEE 1. 00 34 .86 0. 00 34 .86 0. 00 BPFIXTURE UNITS 10. 00 90. 00 0. 00 90.00 0. 00 BPWHEATER PER HEATER 1. 00 10.79 0. 00 10.79 0. 00 BSEISMICRE VALUATION 6, 675. 00 0 .70 0. 00 0.70 0. 00 PPERMITFEE FLAT RATE 1. 00 40.79 0. 00 40.79 0. 00 ----------- ---------- ---------- ---------- TOTAL PERMIT 177 .14 0. 00 177 .14 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 177 .14 #15176 --------------- TOTAL RECEIPT 177 .14 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 0q 0oc;' 3 CITY OF C UPERTINO �� of cuP�r��iNo PERMIT APPLI=CATION FORM i-PN#3 6 (?3 3 � � cJ { O � Date: (?/ Building Address: d Wailing Address (if different from building address): 1060V Owner's Name: Phone#: c/ 'i.S2 -2zs�/ Contractor: License#: Contact: Phone:e411�-V 5-74—'u 5�3 Cupertino Business License#: Fax: 2 Building Pe it Info: Bldg ❑ Elect ❑ F lumb a Mech ❑ Job Description: �G�� Residential fn- Com- cc pct, Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Grou Type of Construction: Please check this box if the project is a G second-story addition: El �-*roject Size: Standard ❑ Large ❑ Maj:)r ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILERZ Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boilei-> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX IncJOff/Comm/Quasi BUILDING BCONSTAXBQ Coil. Tax for BQ Zone BUILDING BCONSTAXH Aotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC 1000 Elec 600V <= 1 OOOA ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 CITY OF C'UPERTINO CUPfr�F PERMIT APPUICATION FORM Quantity Fee ID 'Tee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME N(.w Comm Electric ELECTRICAL BNUCOMMM Nevi Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME In.>pection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE E,Idg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Inc Waste Interceptor PLUMBING BPLANCHK :'Plan Check Fee BUILDING BPLANCKADD Pla 1 Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Rei i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn Sprinkler/Backflo PLUMBING BPSTORM Storm/Rain Water- - PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT A]t of Drain &Vent PLUMBING BPWATER Inst<<ll/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C'Unit> 10,000 cfin MECHANICAL BR.EMAIRHAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BR.EMFIXT Lighting Fixtures ELECTRICAL BREMFURN Re ocation of Furnace MECHANICAL BR.EMFURNOV Relo Furnace> I OK btu MECHANICAL BREMHEAT F-eater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BR.EMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BR.EMPOLE Po e/Platform Fixture ELECTRICAL BREMPOWER Powf r Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA R aocation of Hood MECHANICAL BR.EMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF C UPERTINO aVOF PERMIT APPLI CATION FORM cuPE�iNo ')uantity Fee ID lee Description Fee Group BREMSIGNAD Rind Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR The Arical Lighting Fix ELECTRICAL BREMVENFAN Vert Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Sei mic Commercial BUILDING BSEISMICRE '-'seismic Fee Res BUILDING BSPECIAL S-)ecial Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elee Permit Issuance ELECTRICAL MPERMFEE M-,chanical sq. foot MECHANICAL MPERMITFEE Mec h Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING -- PPLBG - - - Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING 3 )f3 Community Development 10300 Torre Avenue g= Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 "'UPEKTINO Building Department JOB ADDRESS: PERMIT '?0 OWNER'S NAME: t6dI w- PHONE # GENERAL CONTRACTOR: c n &s/, IFAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and co m Mete 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 r/ Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date