06100077 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS: CUPERT INO PLUMBING PERMIT No. 0 610 0 0 7 7
209SS PEPPER TREE LA PERMIT ISSUE DATE
OWNER'S NAME:
LILLY IMARMURE
SANITARY NO. CONTROL NO.
NE:
408 253-0618
PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
o p LICENSED CON-TRACTOR'S DECLARATION Job Description
u I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code.and my license is
<o, in full force and effect O REPIPE- GALVANIZED TO COPPER
License Class Lie.# a S w CHANGE WATER SERVICE
t rp
Date /V—//— Contractor
ARCHITECTS DECLARATI N
oog< I understand my plans shall be used as public records
tyU
U.H Licensed Professional
y OWNER-BUILDER DECLARATION
} I hereby afri.that I am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
?Z r prior to its issuance,also requires the applicant for such permit to file a signed statement Floor Area Valuati
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq•Ft. 0 0 0
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than fire hundred dollars(M). 35912016 . 0 0
❑I,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(fors 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.).
❑I•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 Sea B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
LfJ-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 f ich this permit is issued.
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:
rUZ
Cartier.IT it^`'c— ' PolicyNo.:1252 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor ane 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
2 forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
E~-r 4 1 hereby affirm that there is a construction lending agency for the performance of _
Q!> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
z L.cndees Address
U Q 1 certify that 1 have read this application and state that the above information is
;1." correct.1 agree to comply with all city and county ordinances and state laws relating to
Q Vbuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
in consequence of the rantm rmit. w
U Z APPLICANT UN�EgR; QS h ILL MPLY WITH ALL NON-POINT Issued by:
22PCEREGUL TI9, . —(/— )&
V / Re-roofs
Signature plic on DateT Of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store of handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? n�yy�� All roofs shall be inspected prior to any roofing material being installed.
C]Yes 7�
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? /
Q Yes Nu /
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the buildin r'
does not curter I have athat it is my rcspontihility to notify the occupant of the �~
uircments wh'
�!6
tprior to is a Certificate of Occupancy. S 1 natu�f Appl ht „ 11 Date
g All roof coverings to be Class B or better
Owner o ed agent Date
CITY OF CUPERTINO
of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # : 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN 35912016 . 00
DATE ISSUED. . . . . . . : 10/11/2006
RECEIPT # . . . . . . . . . 36394
REFERENCE ID # . . . : 06100077
SITE ADDRESS 20955 PEPPER TREE LA
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . : LILLY IMARMURE
ADDRESS . . . . . . . . .
CITY/STATE/ZIP . . . :
RECEIVED FROM . . . . : FRANK CARDIA
CONTRACTOR . . . . . . . : CARDIA, FRANK L LIC # 612
COMPANY . . . . . . . . . . : CUPERTINO PLUMBING
ADDRESS . . . . . . . . . . : 1300 DELL AVE, STE C
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 253-0618
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - ---- ------ - ----- ----- ---------- ----
BPREPIPE NO OF FIXTURE 10 . 00 90 . 00 0 . 00 90 . 00 0 . 00
BPWSVCS WATER SERVICE 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
--------- - ----- ----- ---------- ----- ---- -
TOTAL PERMIT 137 . 37 0 . 00 137 . 37 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
CITY OF CUPERTINO wl000l�
REPIPE/S `E. .S/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
Date:
Building Address:
Owner's Name: Phone#:
I �� fry<�rr►��.-�-- <{O�S - �/ �� -- 3�.C-
Contract4: Phone: License #:
L/"7- v�
Conta t: V Phone: Cupertino Business License#:
Building Permit Info: Cj , .- - f_1,�� C(�+ (a �y ,
Bldg ❑ Elect ElPlumb Com' C " I�V U�VuU',�
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
ZO BPREPIPE Repi e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING