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08100112 CITY OF CUPERTINO .0 DIvIsIOri PERNIIT -�CONT£RACTQR INF'URMATION -.1 .BUILDINQ BUILDING ADDRESS: PERMIT NO. 6378 BLACKWOOD DR JENNIFER OH &MARC ARSENAULT 08100112 OWNER'S NAME: PEthirr ISSUE DATE JENNIFER OH &MARC ARSENAULT 6378 BLACKWOOD DR 10/20/2008 NE: SANITARY NO. CONTROL NO. ARCH=/ENGINEER: - BUILDING PERMIT INFO BLDG ELECT PLUMB MECH S C G LICENSED CON RAMR'S DECLARATION O O O O 1 hereby alarm that 1 am licensed under provisions of Chapter 9(commencing Job Description with Samoan]")of Division]of the Business and Professions Code,and my license is REPAIR SWG & ADD CLN OUTS - 2 OUTSIDE OF BLDING o?m in full forte am effect p q z License Clea Lk,0 . Dam ContruLr ?g ARCHITECTS DECLARATION ZZ I understand my plane"I w used An public records s 5� Licensed Professional OWNER-BUILDER DECLARATION COO Z hereby alarm that 1 am exempt from Canvecmrs L,c na law for dw O O following mason.(Section consumes, s,aims and ,derm Code:My oily teatime JKwhich requires issuance.prnnit m cmiWt a rime.improv,h permit u or e a sig any vmclunt Zi Priorbslmmdprsaalso nogoirm the of for such permit Lick aaigncdsunturunt hapMr9 ym< thas hewlkcndpurswntL00)9Disiom ofda,the B.umrmdProkmmutCopter9 Sq.Ft. Floor Area Valuation V-$ (commencing with Section]000)MDivuionl of the Business and Professions Code)or $200 — Net he is eampt therefrom and He basis for the alleged estmpdon.Any violation of Because 7031.5 by a,applicant rte a permit subjects the applicant L a civil penalty of ,,tti�tt Number Occupancy Type mrs.daanftwhunanoddallarsISM 36917049 :trtl� ❑L ss ower of Rio propvty.or my wplayea with wage a Nob role rompensedon, wi0 dodmwork,and the he CrnoranotmLMed LAWdofmsaw(Su.RS as,Buaimit and property who Cadre]Ire Canthomm.License Law doe eat apply lf rt owrcr of Required Inspections property who builds orirepmtsu Hereon,and who dos such work Somali m through M1f. however.the Wilding prust such im is sold it bene year fcmoffertaf finalen. buiWer,deebuilding Works of emvmwmidwithin one year of completion,dee purpose or W iWe will have Ute buNen of proving that k did rot build m improv for pmyna of ly sew.). 1.as taw ser of the property w eachem,cly contracting wide licensed contractors uscame staLa des net pplyAn an wner of and rty whions Code:)The Convenors Li-cents law doer not epp1Y L an awrcr of property who builds or improves tbemen,and, SAN �TARY LWconuacu[m such gojecu with acanvutoKs)Ikemed pursasnlLHe Contractors License law. ❑lam amp uMa See ,BB PCIm Hu nonan 0. Drew I ORKERS COMPENSATION DECLARATION 1 bemby rm under penalty of Perjury arc of the following declandom VI and will mainal)n a CeNfiam ofComem to self-Inoue fm Workers Csmpen- adon.As Provided for by Section 7700 of dee Labor Cade.fm He performance of He work for which this Permit is ivucd. ❑1 have eM will maintain Workers Compensation Imuran,a matured by Section 3700 of He Mbar Code.for one performance of the work for which this permit is issued - My Workers Compensation Immance artier and Policy number art: Carrier. Policy No.: CERTIFICATE OF EREMPRON FROM WORKERS' COMPENSATION INSURANCE ' rmballon wood rothecompkwd if He permil w fm one hundma dollars(5100) or loos,) I certify tin dw performance of He work for which His permit H issued,I shall not topicYan A'T,S.ninalYmanncraamh mcmcmbjecita the Workcre Campcmadon Laws of rsµDate Appli se NOTICE TOA CANT:IL after making Hu Cer iRom of Exception.you should became subjm he aux washers Compensation provisional of the Lahm Codc,you most .J O foMaide amply with such providam or His permit shall he domed rooked. 'Z 0 CONSTRUCTION LENDING AGENCY (-i 1 hereby affirm drat Vert is a coruwcdan lending agency for the performance of ai the wash for which that permit is issued(Sas.7077,Civ.C,) ALenders Natrc .7 z I.,,n.rs Address V Qs:., L ordinances «nify that 1 have read His Application and sum that He above infmondon u LL V correct.I agree comply with all city and county ordinas and slow laws miming w 0 building construction,and hcmbyamhoris aprcaenwtivet of this city to outcrop.ft [i] mWw-mentisncd property for inspection purpaws, LL (Wer)agree m ass,indemnify and kr<p harmless the City of Cupertino Against VI liabilities,Judgments,eaatt and expenw which may in any way masse against said City ' U Z in consequence of He Starting of this parmit. �-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date REGULATIONS. CE R . �^ ids Re-roofs Si APPhanuConvacmr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will He Applicant or fume Wilding oavpanl sous or harMk hazardous materia As def em!by Irk Cupeninc Municipal Code.Chapter 9.13,and the Health and safety Cale.Suction 35331(x)] ❑Ya 9No All roofs shall be inspected prior to any roofing material being installed. Will the apmm plicant or future Wilding occupant use equiprocat or devices which If a roof is installed without first obtaining an inspection,I agree to remove t;l1f us ser conimnts u de0tmd by dee Bay AMA Air Quality Management all new materials for inspection. Ln 1111 ❑Ya 16No 1 have noel He haammumateriaHnoquiromcnu under Chepterfi.95 ofdm Califor- nia Health at Safety Code Sectio uM%5.25537 and 25334.1 undersand thaif Ne Wilding erne ntly hew•mnanl Hat it u my atpansibililY m nctify dm aaupant of dm nal me whkhmuubcmet Priormiauanofa Cmtirwateof O=.p..Y. Signature of Applicant Date All roof coverings to be Class'W'or better Owerm ortrmd agent Dow' CITY OF CUPERTINO • 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36917049 . 00 DATE ISSUED. . . . . . . : 10/20/2008 RECEIPT # . . . . . . . . . : BS000006388 REFERENCE ID # . . . : 08100112 SITE ADDRESS . . . . . : 6378 BLACKWOOD DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : JENNIFER OH &MARC ARSENAULT ADDRESS 6378 BLACKWOOD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JENNIFER OH CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : JENNIFER OH &MARC ARSENAULT ADDRESS . . . . . . . . . . : 6378 BLACKWOOD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- --- ---------- -- ---------- 1BSEISMICR VALUATION 200 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 1PRSEWER UNITS 1 . 00 20 . 40 0 . 00 20 . 40 0 . 00 1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 ---- --------- ------ --- TOTAL PERMIT 102 . 48 0 . 00 102 . 48 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- --------- ---- CHECK 102 . 48 #677 --------------- TOTAL RECEIPT 102 . 48 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING • CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE • CUPEkTINO PERMIT APPLICATION FORM APN # � / / � Date: Building Address:�3�8— AC ��DOD •�� .t�PE PSI(�� 61st)q Owner's Name: �H � Phone #: %94- _G28 Acv Contractor: C4_ZNEOOQEl:) Phone#: 34 :� Zzg S-201 Fax #: Contact: Phone#: Fax #: Contractor License #: Cupertino Business License#: Job Description: � GLC—AtJ W-s _ y O�•`61�� aF �Ut tom( 1 N C� Residential Commercial ❑ Valuation: \ Project Size: Express l❑JStandard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BSEISMICOM Seismic Commercial P 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer CITY OF CUPERTINO REPIPE/SEWERIMAIN SERVICE CUPERTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1PRREPIPE Residential re-pipe per fixture P 1RPRP IBPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P IBPWATER Install/alter Water Pipe P 1BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P IPPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Check P e 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B IBUSLIC Business License B Revised 6-16-08 •