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07050224ri 0 r–r Q z C ,-r U W a z CITY OF CUPERTINO BUILDIN:; DIVISION PERMIT BUIL ES OLLINGER PERMIT No. RD AMERICAN RESIDENTIAL 07050224 OWNER'S NAME: RVT12tLa— PERMIT ISSUE DATE STEVE CASERZD 860 RIDGE LAKE BLVD 05/22/2007 NE: SANITARY NO. CONTROL NO. (408)287—::165 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH C� E (� LICENSED CONTRACTOR'S DECLARATION licensed Chapter 9 Job Description P I hereby affirm that I am under provisions of (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is SEWER SPOT REPAIR-PARKING LOT BOLL INGER / BLANEY . in full force and effect. J Q License Class Lic. A Date '2Contractor ARCHITECTS DECLARATION 1 understand my plans shall be used as public records Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractors License Law for the following reason. (Section 7(Y31.5, 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 SCI. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or $1500 that he is exempt therefrom and the basis for the alleged exemption. Any violation of 1Number 3 6934 052 Ad� �CCII Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 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 forsale (Sec. 7041, Business Required Inspections and Professions Code: The Contractors License Law docs not apply to an owner of Cl P 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. It, 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 Contractor's License Law. ❑ I am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I ha ve 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: O 6� Cagier. ' 0 6/firZPolicy No.: %," J1 5 I CERTIFICATE OF F EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foronc hundred dollars ($100) or less.) 1 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 Ccnificatc 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 construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address I certify that l have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the^\ above-mentioned property for inspection purposes. J ' (We) agree to save, indemnify and keep harmless the City of Cupertino against \\` liabilities, judgmems.Sop and expenses which may in any way accrue against said City in consequence ming of is permit. APPLICA RSTA ND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR LATiO r-Z2' Re-roofs----�--. Type of Roof Signature ol'Applican ontractor Datc HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino MXoal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? All roofs shall be inspected to any roofing material being installed. ❑Yes prior If a roof is instz fled without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminan�s yS defined by the Bay Area Air Quality Management all new materia s for inspection. District? Yes Nu C3®/ 1 have read the hazardous materials requirements under Chapter6.95 of the Califor- nia Health & Safcty Codc, Sections 25505, 25533 and 25534.1 understand that if the building does not currcnftJwVa tenan t it is my responsibility to notify the occupant of the require is ust t or issuance of a Certificate of occupancy. _ Signature of Ap ?licant Date -zZ All roof coverings to be Class "B" or better Oaker or Ittinorizea - 'gelDate 2 ITEMS OF 2 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36934052.01 DATE ISSUED.......: 05/22/2007 RECEIPT #......... BS000001427 REFERENCE ID # ...: 07050224 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 AMERICPN RESIDENTIAL SERVICES ADDRESS 860 RILGE LAKE BLVD CITY/STATE/ZIP ...: MEMPHIS, TN 38120-9417 TELEPHONE (408)2E7-2165 FEE ID UNIT QUANTITY AMOUr'T PD -TO -DT ---------- THIS REC ---------- NEW BAL ---------- ----------------------- BPSEWER SEWER SYSTEM -------------------- 1.00 X1.58 0.00 21.58 0.00 PPERMITFEE FLAT RATE 1.00 -8.37 0.00 ---------- 38.37 ---------- 0.00 ---------- TOTAL PERMIT ---------- `-9.95 0.00 59.95 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 59.95 --------------- 59.95 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER f'_EFERENCE NUMBER -------------------- 00z 246 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 507 FINAL PLUMBING V CUPERTINO CITY OF CUPERTINO REPIPE EWE .SAI.AIN SERVICE PERMIT APPLICI�TION FORM 71��e/e a APN # Date: Building Address: c�Q©%� ,�j'�I �p,5IA-,IPU BPGAS PPERMITFEE Gas P .ping System Fee Plumt,ing Permit Issuance Owner's Name: ��v� G.l�SL1zZA D$ �'� l Contractor: Phone: 677 1Z,UG�-�✓ 2'�Y)-21 License #: EJG� Contact: Phone ) Cupertin Business License #: P v , be / BPSEWER Building Permit Info: PLUMBING Bldg El Elect El Sewage Disposal Job Description: Job WP� S Ufi Q�� Residential [i Commercial Cost of Project: /�500 Business License .11 Qty. if Fee Groun K AppiicaDie rcv, BPERMFEE - -- - -----r Bldg. Permit Fees - BUILDING BPGAS PPERMITFEE Gas P .ping System Fee Plumt,ing Permit Issuance PLUMBING PLUMBING BPREPIPE BPFIXTURE Repipe of Fixtures Pblg. Fixture PLUMBING PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING 1,i3 C1L 2 CIN OF "UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Buildin ; De artment JOB ADDRESS: PERMIT # D 8 e3 ,Va�G7/ �✓� OWNER'S NAME: PHONE # - a0960' GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date .,_ Please check applicame suncontraccurs =SUBCONTRACTOR culu w11L 1ClC 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 C� Owner/ Contractor Signature ;5---/7-07 Date