08110003 CITY OF CUPERTINO
BUILDM,'C DIV], PERMIT , CUk�ITRA TOR INIE'QTtMA.T. f)ly ;
.LON "'VT I'-Tmyx a ..•*v, .vY,R.b'!' H4�siHso ,� ,.ex,,
BUILDING ADDRESS: PERMIT NO.
1
OWNER'S NAME: PERMIT ISSUE DATE
60
SA CONIROLNO.
ARCHIEC(ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
WATER HEATR REPLCMENT O O O O
LICENSED CONTRACTOR'S DECLARATION
uC I hereby a(Brm euf 1 w Iimnaed under provi4ons of Chapter 9(mmmencing Job Description
2 U wi
w NSation]OnU)ef DivialonJaf dce Budoss tad Profesdons Code.and mylicensus
or
full form and e 4
j M i
L. If JE
Clus Lk.N
t„q Dau: Contractor
7W As shall use DECLARAT i
6
U 1 undenunJ my plans shall bo used u WFII,rteords
g LiccmeI Professional
y OWNER-BUILDER DECLARATION
E<I 1 hemhy Alum o
that
I am exempt from the Lesions o Licence law for the
p O following moon. emit t RI3 sLS,lo Business and w,derons Code:Any city or roomy
$ which its iso n permit re<oswct alter,W prow,h permit t or mesh ed awmtm
Z_> prior e l Issuance,ausu esquires the applicant for such permit m file a signed sulemem
< Nat rte is nmnsed pmrv.mmNe provismnsorthe conuacmra tieonsn law(cn.pr9 Sq.Ft.Floor Area Valuation
00 that W s ora ith Send ors and th basis for
them Bae cone red on.Anyoms Code)or
y�$ Net he u eumpt thw(rom and dce buts fm the alleged uempean.Any violation of
Seedon 7031.5 by any appneat for a permit subjects the applicant m a civil Penalty of APN Number Occupancy Type
mot more don But hummed dollars ISM
I,uowrcr oftk propertY•mmy wplcyca with wagesuecev sole compntaeon,
will do the wok and thestsmmute u net intended orolferW forsam(Sec.70x4.Bualr...
and Professions Code:The Conbumr's Limme Law does not apply n an nwner or Required Inspections
property who buildsorimproves descent.andwW dossuch wart himselfmduomgh his
own wployces,provided that such improsemmu w not intended oraRertd(wale.B.
howxs .fee Wilding us isnprovemml U sold within rn year ofctmpletim,the ower-
builder will Nle site btndo of proHng mat M did nn build or improrc her purpose of
sale.).
1.u owner of the property.for exclusively co mens ing with Bran-^mnvclms to
construct tin proem(Sec 7044.Bl w.add Profoseb ns Code:)lin Cmracmr'.U.
come,law deea not appy m an comer of Property who WOds of Wptowa dnroen,Me .
who com me u for such p.jema with a mnracnr(s)beensd pusemom as the Conuawfa
limns Law.
❑I am exempt under See ,R At P C for this reason
Demmer Dan
WORKERS COMPENSATION DECLARATION
1 hereby alarm under peulfy of perjury Once of the following declarations:
1 ham and will maintain aCr>ti0ote of Consent self-inmm for Worker's Compere
on,u provided for by Section 3700 of the labor Code.for the performwce of do
mk for which Nis permit is Issued.
❑1 have and will mainmin Worker's Compensation Insmanm,as requited by Session
3M of the labor Code,for the performance of the waste for which this permit is issued. '
My Worker's C penuuon Insurance caroler and policy
nu/-W,see:
Carrier. PoBcy NO.: WORKERS'[ ' L3I
CERT( COMPENSATIOATE N
NFROM WORKERS
COMPENSATION INSURANCE
(Thussectlon sed Out be completed ifthe permit Is from hummed do0ars($I00)
mlus)
1¢tif•that in the performanm of the work for which this permit is issued.l shit not
employ any person in say marroorso as an become subject to de W.Hucre Compenudon
laws of Califomia.Dw
Appllmm
NOTICE TO APPLICANT:If.after making this Cenifimm of Exemption,you should
become subjeer,un dm WarkeYa Compensation provisions of the Ichor Cndt,you mous
.�z forthwith comply with such provisions Or tris permit shall W domed onmkcd.
CONSTRUCTION LENDING AGENCY
(••�� I hereby alBnn this Vert u a muruminn lending ageney fm Ute perlmmans of
Ci 5: the woh for which thus pewit is issued(See 3097.Civ.C.)
1 Q lender's Name
z IanAces Address
U O I certify that 1 haw rod this application and state this the above information is
I,P corral 1 agree to comply with all city and comfy ordinances and sate laws relating he
'0 U Wilding construction,and hereby mNosi>a rep.tatives of Nu city to enter upon Ne
4r7 above-mentioned property for inspection purposes.
(We)agree to taw,indemnify tad keep harmless the City of Cupertino agalnsl
it Z incO0rPecoc Ofth,emu tad expemeswhtch they in tiny w.y active against aid Ciy
U,'� A cPLIC NT or the lintruffintUNDERSTANDS
of this D WILL COMPLY WITH All NON-POINT Issued by: Date
SOURCEREyIA'G
C I hl�0.3 Re-roofs
Sig...of A,IMurYCoasme... to
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the apPlicxm or future Wilding oaupantsms or handle ha>ardou material .
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safely
Code.Section 25532(+)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ErN.
Will the applicant err future Wilding ac.part mry of u mcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
't hva tux air cmmminsnu u defined by the Bay Area Air Quality Management all new materials for inspection.
utet7
❑Yes 9K.
1 haw mad ece bvvdms materusustequimmem unhr Chap=6.95 oftheCdifm-
nuHalthhSalmyCodo Sadmo25505,25533and23534.1undrmum NmifNe Wilding
docs not suwney low a tenat,dap it is my responsibility to ratify the occupant of the
mgtirednm.whlehmurbome ,heisamceof.Certircateof0em Signature of Applicant Date
0
t ;
Owner or auNori>nd agem All roof coverings to be Class'n"or better
a¢' '
CITY OF CUPERTINO
• 4 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 34232053 . 00
DATE ISSUED. . . . . . . : 11/03/2008
RECEIPT #. . . . . . . . . : BS000006526
REFERENCE ID # . . . : 08110003
SITE ADDRESS . . . . . : 10033 LONG OAK LN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LAKSHMI PARTHASARATH
ADDRESS 10033 LONG OAK LN
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5613
RECEIVED FROM . . . . : ALL VALLEY PLUMBING
CONTRACTOR . . . . . . . : MARY SANDBRINK LIC # 23015
COMPANY . . . . . . . . . . : ALL VALLEY PLUMBING
ADDRESS 3345 SELDON CT
CITY/STATE/ZIP . . . : FREMONT, CA 94539
TELEPHONE . . . . . . . . : (510) 376-4816
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ----------- ----
1BSEISMICR VALUATION 300 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 .48 0 . 00 24 . 48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79. 0 . 00
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- - -------------------
CHECK 323 . 12 #1730
---------------
TOTAL RECEIPT 323 . 12
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
----- ---------------------------- --------
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518 WATER HEATER
•
CITY OF CUPERTINO 0 Ll
WATER HEATER
-WarM
CUPERJINO VERIMIT APPLICATION FOR
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_oc-l- Pace t
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attached to this application.
and atta
-een Check must b
e completed 1'reen Building Points achieved: