07030051 CITY OF CUPERTINO � � � ZE(}RMATIQN;
BUILDING'DIVISION PERMITX.
PERMIT NO.
BUILDING ADDRESS:
21490 MC CLELLAN RD GREAT AKERICAN PLUMBING CO 07030051
OWNER'S NAME: 1 PERMIT ISSUE DATE
GERALD BETTANCOURT 166 GRkHAM AVE
03/08/2007
SANITARY NO. CONTROL NO.
SNE:
(408) 279-1515
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
cc LICENSED CONTRACTOR'S DECLARATION Job Description
U1 hereby affirm that I am licensed under provisions oC Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Profession.r.,4� . titnse is BURST PIPE 14 0 FT FROM BLDG TO PROPERTY LINE &
t y in full force and effect j 1 7 ( t y
Z License C�ssLi�x— ��
IN LL CLEANOUT.
Date / Contractor
RCHrrECTS DECD_-...-. ,
j C< t understand my plans shall he used as public records
)aU
U.h Licensed Professional
O a OWNER-BUILDER DECLARATION
<� I herchy affirm that 1 am exempt from the Contractor's License Law for the
9001 following reason.(Section 7031.5,Business and Professions Code:Any city or county
<�� which inquires a permit to construct,alter.improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
-?< that he is licensed pursuant to the provisions of the Contractor's Uccase Law(Chapter 9 Sq $11200
Z O (commencing with Section 7000)of Division 3 of the Businrss and Professions Code)or
L 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 N Number
not more than five hundred dollars(5500). 36201027 �V
❑1,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 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.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)'Me Ctmtractries Li-
cense Law docs 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.
❑lam exe under c. B&P C for this reason
Owner Dat
S ATION DECLpRP.TION
I hereby affirm under penalty o one of the following declarations:
❑I 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.
2-fhave 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.
Mp Worlrr's Mmnnnsarnn tnsnranee carrier and Policy number are: 3<
I (�k l n S CERTIFICATE OF E7(E�gPII�ON FROM WI OGRKERS'
COMPENSATION INSURANCE 4D
(This section need not be completed if the permit is formic 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 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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
a, > the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
LUT.F correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
W ahovc-mentioned property for inspccuon purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
rA
F" 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
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURC A
- - - Re-roof:
u Applitand6 r ALS DISCLOSURE Dare Type of Roof
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 roof;shall be inspected prior to any roofing material being installed.
❑Yes Zwo
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 materials for inspection.
District?
❑Yes o
I have read time hazardous materials requirements underChapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not c tly have tenant,that it is my responsibility to notify the occupant of the
reyuircm rats hi must) "IlttRTrior to is;uke of a Certificate ofpang. Signatw a of Applicant Date
All roof coverings to be Class "B"or better
or au Da
CITY OF t:UPERTINO
REPIPE/S W E I .S/MAIN SERVICE 07
CUPEkTINO PERMIT APPLICATION FORM
APN # D te:
� � C,� �j� �
Buildin ddre : �)
O ner's N Vhheyontractor: Ph ne: se#:
_ (,1(2j
tact: P ne _ Cupertino Busine s License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Deseriptiow
esidential ❑ Commerc•
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS (Jas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE 1'blg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE 'Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN 36201027.00
DATE ISSUED. . . . . . . : 03,08/2007
RECEIPT #. . . . . . . . . BS0)00000635
REFERENCE ID # . . . : 07()30051
SITE ADDRESS 21,690 MC CLELLAN RD
SUBDIVISION . . . . . .
CITY CU'.?ERTINO
IMPACT AREA . . . . . .
OWNER GE]2ALD BETTANCOURT
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO, 75221-
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR CO.ZPORATION LIC # 18061
COMPANY GR3AT AMERICAN PLUMBING CO INC
ADDRESS 165 GRAHAM AVE
CITY/STATE/ZIP . . . : SAJ JOSE, CA 95110
TELEPHONE . . . . . . . . : (4D8) 279-1515
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 38.37 0 .00 38 .37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 59. 95 0 .00 59. 95 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 59. 95 99608
---------------
TOTAL RECEIPT 59.95
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ---------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING