06100129 CITY OF CUPERTINOEtT � ;
BUILDING,DIVISION PERMIT
BUILDING ADDRESS: NEW STRUCTURE PLUMBING IN PERMIT NO.06100129
PERMIT ISSUE DATE
OWNER'S NAME:
DON r- PAT NAGEL SANITARY NO. CONTROL NO.
iNE:
4 0 8 364-2143 BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
C=
etZ LICENSED CONTRACTOR'S DECLARATION Job Description
iVp I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z U, with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y in full force andeffect. 50 ' OF 1/2" GAS LINE FOR LOG SET IN EXISTING
License Class Lic.If FIREPLACE
p Contractor Date
E to ARCHITECTS DECLARATION
i�< 1 understand my plans shall he used as public records
iyU
U. Licensed Professional
a OWNER-BUILDER DECLARATION
3<z 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
:p op� following reason.(Section 703 1.5,Business and Professions Code:Any city or county
% ti which requires a permit to conswct,alter,improve.demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statementValuati nl 5 0 0
S Ft.Floor Area
?t that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
t=- (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 APN Number 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(5500)• FE 34255019 - 00
0 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.).
0 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-
ccnse 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' B&P C for is on
❑I am exempt under Sec
1-11 7
Owner
-z, _.. . I.,„.tl J 1�, U1j��Date
WORKER'S COMJA ¢AT70 CLARATION
I hereby affirm under penalty ofperjuryone of the following declarations:
0 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.
0 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:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one 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 s�makjng
�crti
' q the Workcrs'Compensation
Laws of alifomia.Date b
Applicant
NOTICE TO A PLICA :If, ftte of ption,you should
become subject to the Worker's Compensation provisions of the Labor Code•you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
(~�r. I hereby affirm that there is a construction lending agency for the performance of
�.5 the work for which this permit is issued(Sec.3097,Civ.C.)
(L)Q Lender's Name
L>+ Lcndees Address
U C) I certify that 1 have read this application and state that the above information is
L>~H correct.1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W (We)agree to save,indemnify and keep harmless the City of against
s against
CA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
C.PQWRe-roofs
Signature of Applic Contractor Da1e T of Roof
HAZARDOUS MATERIALS DI OSURE Type
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 roofs shall be inspected prior to any roofing material being installed.
0Yes 04
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 contaminakN.
ined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant•that it is my responsibility to notify the occupant of the
requirements which must be m prior to issuan f a Certificate of OccupancySignature of Applicant Date
t 10117 All roof coverings to be Class"B"or better
Owner or authon-A agent Date
Community Development
10300 Torre Avenue
'{ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
' UPEkTINO
Building Department
JOB ADDRESS: �3 PERMIT #C,;t.**'j
z3 v,� gs
OWNER'S NAME:-6-,�- f PHONE # (a 5'0- 016 8^ Z Y-
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: Le;,., �/ _ �. (► 6
Signature Date
Please check applicable subcontractors and complete the following information:
21 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
Sheet Rock
Tile
1
Owner/Contractor ature Date
CITY OF CUPERTINO
1 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34255019.00
DATE ISSUED. . . . . . . : 10/17/2006
RECEIPT #. . . . . . . . . 36470
REFERENCE ID # 06100129
SITE ADDRESS 23200 VIA ESPLENDOR #34
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER DON & PAT NAGEL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM TOM K WAUGH
CONTRACTOR LEON FRIDLIB LIC # 26052
COMPANY NEW STRUCTURE PLUMBING INC
ADDRESS 631 KENNETH AVE
CITY/STATE/ZIP CAMPBELL, CA 95008
TELEPHONE (408) 364-2143
SEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -----
BPERMFEE VALUATION 1, 500.00 83 .16 0.00 83 .16 0.00
BPGAS OULETS 1.00 5.40 0.00 5.40 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 126.93 0.00 126.93 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------
OTHER 126.93 M/C
TOTAL RECEIPT 126.93
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
CITY OF CUPERTINO
REPIPE/SJ S/MAIN SERVICE f^� &nx,?c11 f V �Y
CUPEI�TINO PERMIT APPLICATION FORM
APN# Date:
3 YA L�—)l 5�- 1
Building Address:
Owner's Name: Phone#:
Dlofv � - Z ,S
Contractor: Phone: License#:
S
Lt VIA 3!v ZI 3 C36 & 372Y'F
Contact: Phone: Cupertino Business License#:
Lenk, F V- - Zr V3
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Descriptio � V (' ) J j
/-Z !� en> C i ✓�
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
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING