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07050265CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILD G DD ESS: PERMIT NO. �NOS4fi BOLLINGER RD AMERICAN RESIDENTIAL 07050265 OWNER'S NAME: RVic 5 PERMIT ISSUE DATE STEVE CASERZD 860 RIDGE SAKE BLVD 05/29/2007 )NE: SANITARY NO. CONTROL NO. (408)287-2165 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3ofthe Business and ProfessignsCode, an)mylicense is REPLACE SEWER LATERAL W/PORPERTY LINE CLEAN OUT. in full force and effect '2 QJ 3 y 1 License Class Lic. # J l) Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 703 1.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 Sq. F:. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or $ 3 5 0 6 that he is exempt therefrom and the basis for the alleged exemption. Any violation of Number Occupancy Type P Y YP Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of net more than five hundred dollars (35M). 36934052q. ❑ I, as owner of the property, or my employees with wages as their sole compensation, Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business 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 We. 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:) The Contractor's 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. TARY ❑ 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: L] 1 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. ❑ 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 Worker's Compensation Insurance carrier and Policy number arc/: e Carrier: dGE J*MeX:-C4 r �P J _ Policy No.: � ).e_- % 6 31 il CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section treed not be completed if the permit is forone hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, 1 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 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a concoction lending agency for the performance of the work for which this permit is issued (See. 3097, Civ. C.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is Correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorr-re representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, cos d expenses which may in any way accrue against said City in consequence of ng of th' tt. APPLICA D ANDS WIL OMPLY WITH ALL NON -POINT Issued by:i4Date --� Zed 7 SOURC TIONS. C zo, — 12 - Re -roofs Signature ofApplicant/Con for Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof i mg occupant store or handle hazardous material Will the applicant or fu2No as defined by the Cupertino Mal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? All roofs shall b-- inspected to any roofing material being installed. ❑ Yes prior If a roof is instar led without first obtaining an inspection, I agree to remove Will the applicant or future ilding occupant use equipment or devices which emit hazardous air contaminants defined by the Bay Area Air Quality Management all new material; for inspection. District? ❑ Yes No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safcty Codc, Sections 25505,25 33 and 25534.1 understand that if the building docs not curie have a t Utas it y responsibility to notify the occupant of the requiremc him. I - iaatlatt�enraC«tirkmirOccupancy. S _ Z� 7 Signature of Applicant Date All roof coverings to be Class "B" or better O er or authorize gent Date CITY OF CUPERTINO 2 ITEMS OF 2 PERMIT FECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36934052.01 DATE ISSUED.......: 05/29/2007 RECEIPT #.........: BS000001483 REFERENCE ID # •..: 07050265 SITE ADDRESS .....: 20041 BOLLINGER RD SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ......: OWNER STEVE CASERZD ADDRESS 20041 BOLLINGER RD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: suew COPY # : 1 RECEIVED FROM ....: RESCUE ROOTER CONTRACTOR DONALD KARNES LIC # 21504 COMPANY AMERICAN RESIDENTIAL SERVICES ADDRESS 860 RIDGE LAKE BLVD CITY/STATE/ZIP ...: MEMPHIS, TN 38120-9417 TELEPHONE (408)287-2165 FEE ID UNIT ----------------------- QUANTITY AMO7NT -------------------- 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 ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 59.95 --------------- 59.95 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER REFERENCE NUMBER -------------------- 0)4250 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 507 FINAL PLUMBING CUPEkTINO CITY OF CUIPERTINO REPIPE/SHERS/MAIN SERVICE PERMIT APPLICATION FORM APN # j 61 -3L1 OsZ - -- — -----r --- Bldg. Permit Fees Date: Building Address: Gas Piping System Fee PLUMBING / PPERMITFEE Plumbing Permit Issuance PLUMBING Owner's Name: Repii)e of Fixtures PLUMBING Phone #: :t5 TF—VE ,v E- z -P BPWSVCS Mair. Water Service Contractor: Phone: 2 License #: t 3 Y R-ooh',1� Phone: Cupertino Business License #: Contact: p A c> i LEE (C/05') 3-1:3-2-Z'7-2-- J Building Permit Info: BUSLIC Busi less License BUILDING Bldg El Elect ❑ Plumb Lid Job Description: — vv -c- YL Ll ->T EIz o L b`n�� Nom' �✓ y , P �� O Residential ❑ Commercial [� Cost of Project: 3 6 Qty. if r.TT-1_� rr Fee nescrintion Fee Group Appiicanie rG� 113 BPERMFEE - -- — -----r --- Bldg. Permit Fees - BUILDING BPGAS Gas Piping System Fee PLUMBING / PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Repii)e of Fixtures PLUMBING BPFIXTURE Pblg. Fixture PLUMBING BPWSVCS Mair. Water Service PLUMBING / BPSEWER Sewfsrs PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Busi less License BUILDING Community Development a 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 CITY OF 'UPEkTINO Buildin tue artment JOB ADDRESS: PERMIT # 'ZQ h for a OWNER'S NAME: PHONE # GENERAL CONTRACTOR: -jg� I am not using any subcontractors: Signat-ire Date Please cnecx dVVjjLCjUjLV= Z0UV%-U1LuaL.L�1J-- 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 She Rock Tile Owner/ Contractor Signature Date