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07090178 77777777777..,., CITY OF CUPERTINO BUILDING DlViSlON PERMITQ) .CT�??R� +f31VIATION PERMIT NO. BUtI 1 l?g A TR ENDERGAST AVE TBD — TC BE DETERMINED 07090178 tj`�U(J PERMIT ISSUE DATE OWNER'S NAME: ADRIENNE HARBER 09/26/2007 SANITARY NO. CONTROL NO. )NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH p O LICENSED CONTRACTOR'S DECLARATION Job Descriptionm— 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Wu ul with Section 7000)of Division 3 of the Business and Professions Code,and my license is SEWER M7 t I N o y in full force and of t, / t ? License CI Lic.k p Datc Contractor m RCHITEcrs DEC LA ATION i a< 1 understand my plans shall he used as public records )dU W in Licensed Professional a OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the jp 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 )'rn prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $4000 O O aF$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or c 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 37533042 . Number not more than five hundred dollars(5500). 0 1,as owner of the property,or my employees with wages az their sole compensation, will do the work and the structure is not intended oroffered 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.). 0 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Conuactoes Li- cerise 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. RY 0 I am exempt under Sec. B&P C for this reason SANITA Owner Date - - WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ZI 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. 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 Workers Compensation Insurance carrier and Policy number are: Cartier. Policy No.: 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 am cr�so az t�cc�c 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 O CONSTRUCTION LENDING AGENCY HCA I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued(See.3097,Civ.C.) Gfa Q Lender's Name Lender's Address U 0 1 certify that 1 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 rJ Ubuilding construction,and hereby authorize representatives of this city to enter upon the W above-mcntiuncd property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against —� Q" ►�-t toliabilities,judgments.costs and expenses which may in any way accrue against said City G U Z in consequence of the granting of this permit. Date 2 .ty-7 �+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b} SOURCE REGULATIONS. Re-roofs Signature of Applicant/Contractor Date Type of Roof MATERIALS DISCLOSURE yP 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 shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant or future 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 defined by the Bay Area Air Quality Management all new r iaterials for inspection. District? 0 Yes el No I have read the hazardous materials requirements under Chapter 6.95 of die Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building docs not currently have a tenant,that it is my responsibility to notify the occupant of the require cn which must be mel prior to issuance of a Certificate ofpanq Signaturf:of Applicant Date of Date All roof coverings to be Class"B"or better Owner or authorized agent Date -7c)9 01 � CITY OF CUPERTINO REPIPE/SEWEPkS/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN#3-7 Date: _ � ;5 c) a . Building Address: l-6('AO O Owner's Name: Phone#: , Co,ntr ctor: � License#: i L� Contact: 1 Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Job Description: �toF-g LAAa,� Residential Commercial ❑ Cost of Project: GCI • °c) Qty. if Applicable Fee ID Fee Description Fee Group PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE lte i e of Fixtures PLUMBING BPERMFEE Bldg. Permit Fees BUILDING BPFIXTURE l'bl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT' RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: B1}:: Lot: APN 37533042 . 00 DATE ISSUED. . . . . . . : 09,'26/2007 RECEIPT #. . . . . . . . . : BS000002766 REFERENCE ID # . . . : 07090178 SITE ADDRESS . . . . . : 18900 PENDERGAST AVE SUBDIVISION . . . . . . CITY CU::ERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ADRIENNE HARBER ADDRESS . . . . . . . . . . : 18900 PENDERGAST AVE CITY/STATE/ZIP . . . : CU:?ERTINO, CA 95014 RECEIVED FROM . . . . : BENJAMIN OCHOA CONTRACTOR . . . . . . . : TB:) - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TB=) - TO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : 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 40 .79 0. 00 40.79 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 169 .37 0. 00 169 .37 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 169 .37 VISA --------------- TOTAL RECEIPT 169 .37 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 C1T1f OF Fax(408)777-3333 -,UPEkTINO Building Department JOB ADDRESS: PERMIT # SIR% L,It rib lf,700 pe"Jey-r OWNER'S NAME: ` PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: /�� Si:;nature 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 Rock Tile Owner/Contractor Signature Date