07100167 CITX OF CUPERTINO '
BUILDING DIVISION PERMIT ���iT`k���`��� I:��"����TION: <
,: ,:.: . :: __ _ , _
- PERMIT NO.
BUILDING ADDRESS:
1 �1 FA � Fn'nmuTr r��,�
A
:R'S NAME:
S � �] CONIROL NO.
PHON .
BUII.DING PERMIT [NFO
ARCH]TECI'lENGINEER: BLDG ELECf PLUMB MECH
� � 0 �
> o LICENSED CONTRAC7'OR'S DECLARATION JOb D0SCi1pt10D
�� I hcrcby affirtn that I am liccnscd undcr provisions oC Chap�cr 9(commcncing
:� with Scction 7000) of Division 3 of thc Busincss and Protcssions Codc, and my liccnsc is
�0. infullforceandeffec� PROPERTY LINE CLEANOUT
3 Z Liconsc Cl Lic. ii ��� �
.p Da�c 1�0/:Z.'S o7 Coniractar
: � ARCHITECTS DECLARATION
%� 1 undcrstand my plans shall bc uscd as puAlic rccords
;a
U
F' Liccnscd Pn�fcssionat
� a OW NER-BUILDER DECLARATION
��
1 hcrcby affirm that 1 am cxcmpt from thc Convactor's Liccnsc Law for thc
j O following �ason. (Scction 7031.5, Busincss and Profcssions Coc1c: Any city or coun�y �
;�i which rcquires a pcmiit to conswc4 altcr, impmve, dcmolish, or repair any swcture
; y prior �o its issuaiuc, also 7cquircs thc applicant for such permit to filc a signcd siatemcnt , Ft. F�00I' e�lI'e2 V31UaC10❑
u
' a �ha� he is IiccnscJ pucsuanl t0 thc provisions of thc Conlractor's Li�xnsc Law (Chaptcr 9 Sq
Cp
-$ (commencing wiih Scction 7000) nf Division 3 oC �hc Busincss and Profccsions Codc) or
L.. that he is exempt therefrom and the basis for �Ae allcgcd eumption. Any violarion of
Section 7031.5 by a�ry applicant for a permit subjects the applicant to a civil penalty of APN Number Oeeupaney Type
not more �an five hundred dollars (SS00).
❑ I, at owncr of ttrc property, or my employca with wagu as �hcir solc compensauon, 3 4 214119 . � �
will do Ihe work and Ihe strocture is not intendcd w offered for salc (Sec. �044. Business Required Inspections
and Professions Code: The Conuacwr's License Law docs not apply �o an owner of
propeny who builds or improves theceon, and who does such work himsel[or th�ough 6is
own employces, provided that such improvementt are not intended or otlered for sale. IC.
hawever.lhe building or improvement is sold within one year of tompletion, the owner-
builder will have �he burden ot proving tt�at hc did not build or improve Cor purpose of
salcJ.
❑ 1, as awner of the property, am exclusivcly conuacting with licensed contractors to R;' 'i' �
wnsuvct the project (Sec. 7044. Business and Protessions Cade:) The Comractor's Li- ��«
cense Law docs not apply w an owner o( propeny who builds or improves U�ereon, and , y �
who contncts for such projects with a contractor(s) licensed pursuant to �he Convacwr's
License L.aw.
[� 1 am ezempt under Sec , B& P C tor this rcason
:� o�� 3 0
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of �►u following declarations:
❑ I hsve and will maintein a Cenificate of Consent to ulf-insure for Worku's Compen-
sation, as provided for by Section 3700 0! the Labor Code, for 1he performance of the
woric for which �his permit is iuucd.
❑ I havc and will maintain Workcr's Compensation Insurana, as tcquircd by Scction .
3700 oC thc Labor Codc, for thc performsncc of �he woric for which ihis pcimit is issued.
My Workefs Co pensation Insurance carrier and Policy numbe are:� Z
Cartier. ���'fwh � �SufWYJ��Policy No.: �u) � �1J176� � J
CERTIFICATE OF EXEMPTTON FROM WORKERS'
COMPENSATION tNSURANCE
(This scction necd rrot be complc�cd if the pcm�it is far onc hundrsd dollars (5100)
or Icss.)
I cenify that in thc performance of thc work tor which �his pertnit is issucd. t shall oot
employ any person in any ma r�cf ea� ujG � c subject to �he Workcrs' Compensadon
Laws of Cal'i.9r�'�. D�u 1t. ;
Applicant �.y ��
NOTICE TO APPLICANT: If, aftcr making �his CcrtiCca�c of Excmpuon, you should
bccome subjcct to �hc Workcr's Compensation provisions of Ihc Labor Codc, you muu
� O fortMwi�h comply wi�h such provisions or this pccmit shall bc dcemcd revokcd.
""' CONS7RUCf10N LENDING AGENCY
�.�-+ I herchy aftirm �hat there is a consuuctinn lending age�y Cor ihe performance of
�� ihc work for which �his pemiit is issucd (Scc. 3097, Civ. C.) ,
7 Q L.endcr's Namc
� z Lcnders Address
)
� 0 I certify �hat I have read this applica8on and s�a�c ihat thc above infocmaliun is
►�+ cortcc� 1 agmx to rnmply with all city and county onlinances and s�atc laws relating to
j U building consuuction, and hercby authori�e representativcs of this city to cmct upon �hc
�
W abovc-mcnGoned properly (ot inspccuon purpous.
� a (Wc) agree lo save, indcmni(y and kccp harmless ihc Ciry af Cupertino against
�� liabilitiu, judgmcnts, costs and expenses which may in any way acrnx againsl said City
) z in consequencc oC �he granting ot Ihis permit. DaCC
"'� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOURC TIONS. r
���2 �/o� Re-roofs
Signawm of ApplicanUConuac�or Da� T e of R oof
HAZARDOUS MATERIALS DISCLOSURE yp
wll �hc appticant or futurc building occupant storc or handlc haiardous maicrial
iefincd by thc Cupenino Municipal Codc. Chaptcr 9.12, and the Hcalth and Safcty
c. Scction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
� Ycs �o
WiII the a�licant or futurc building accupant use equipment or dcvices which
If a roof is installed without first obtaining an inspection, I agree to remove
cmi� harardous air con�aminants u dcfincd Ay ihe Bay Arca Air Quality Managcmcnt all new n aterials for inspec dl011.
District? F ��
�Ycs �No . �
,-' -:
I havc rcad the hvardcws maicrials requiremcn�s undcr Chap�cr 6.95 of thc Cali[o � � ',,.-'" � '� �C j/��
nia Hcalth & Safc� Codc, Secuons 25505, 25533 and 25534.1 undcrsund thu �C U�c bw1d�� "�"�'��' � i J7
docs not curtcnily havc a �cnan4 �t it is my rcsponsibiliry w naiCy �hc occupent nf Ihc � f„ � _.__ `-�
�
rcyuimm mun bc me br to issuancc tkatc ot cup cY• � natur€ of Applicant ---'' , Date
�6i'`'3�d7 Al� roof coverings to be Class "B or better
Owncr or authori�,cd agcn� Datc -
o� ��� � c��
� CITY OF CUPERTINO
V { f :� REPIPE/����j�.���.�/MAIN SERVICE
CUPEI�TINO PERMIT APPLICATION FORM
APN # Date:
0 ��a � � 10 �.3 v�
Building Address:
�-O�f��� `� . �oo i � 1.► -
Owner's Name: Phone #:
c�.�' v �, ��8-�-3°I—��°�6
Contractor: Phone: License #:
( r Pluw►b�n (�, . yOg-d!3 `73a2 611
Contact: Phone: Cup rtino Business License #:
; �o( �'. � < < yo�- �,�►°�- 70�� �a �g9 0� � o�
Building Permit Info:
Bldg � Elect ❑ Plumb �,
Job Description:
ro e� �- l iv� � ��- -
Residenti 1 � Commercial ❑
Cost of Project: � o
� 3�0.
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE �31dg. Permit Fees BUILDING
BPGAS (Jas Pi ing System Fee PLUMBING
PPERMITFEE �'lumbing Permit Issuance PLUMBING
BPREPIPE �;epipe of Fixtures PLUMBING
BPFIXTURE �'blg. Fixture PLUMBING
BPWSVCS r�ain Water Service PLUMBING
BPSEWER ��ewers PLUMBING
BPSEWAGE ��ewage Disposal PLUMBING
BUSLIC Ftusiness License BUILDING
CITY OF CUPERTINO
ITEM 1 OF 1 PERMIT RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 34214119.00
DATE ISSUED.......: 1C/23/2007
RECEIPT #.......... B�000003062
REFERENCE ID # ...: 07100167
SITE ADDRESS .....: 1C169 S FOOTHILL BLVD
SUBDIVISION .......
CITY .............. CLPERTINO
IMPACT AREA .......
OWNER ............. SPNDRA BURCH
ADDRESS ..........: 1C169 S FOOTHILL BLVD
CITY/STATE/ZIP ...: CL;PERTINO CA, 95014-2601
RECEIVED FROM ....: NICHOLAS J FILIPPI
CONTRACTOR .......: DLP..RTE TADEV LIC # 22189
COMPANY ..........: ALLSTAR'PLUMBING
ADDRESS ..........: 326 PHELAN AVE
CITY/STATE/ZIP ...: SPN JOSE, CA 95122
TELEPHONE ........: (408) 230-5569
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
PPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 40.79 0.00 40.79 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 40.79 VISA
---------------
TOTAL RECEIPT : 40.79
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
506 GAS TEST •5C7 FINAL PLUMBING
FROM :CUPERTINOSANITARYDISTRICT FAX N0. :��082535173 Nov. 01 2007 09:25AM P1
�� $#. rA�r�.� BOARD OF DIRECTOR6
DI8TRICT MANAGER S „r.
� � JE� 'P�. 6'f�PFiEtJ C. /�NDR�WS
MARK'['MOMAg & COMPANY, iNC. `�� A
W1L,LiAM A. Ba9WOR'TH
DAVID �. RO�S r
YF:At�S {1F JOkiN M. G/1TT0
(�ISTRICT C�UI�S�L 5EE�VI' ; F. �� CUR71S B. HARRI��N
/�TK[NS�f�[ • FARA9YIQ, Ll.P. � 1 � W�NDELL H- KERR, JR.
FiAROLO 9. TOPPEL
aOB33 ST�VENB CR�E < BOULEVAFRb, SUI'f'E 104
CUp�RT1N0. CAL. FOF2N[A 8g044 �4
(4Q81R�'907i �HOT�� • (406)289�173F'AX
www,c��pertinos�nitarydistrict.corn
F;��: cUsn . �vr.o�3
Iiuilding Uept. — Cupertino
C;ity of Cupertino
�1ttn.: Buildin�; Department 3
] 03U0 Torre Ave. � 1� �
CupexE�no, CA 95()1.4�3202 �
�.
Subject: ln�tall Property lai�ne C=�eano�at
Name: San.dra R'�rch
Add.ress: 101 fi9 S Foothily Blvd.
APN: 342-14�119
�'crmit No. 071001.b7
No uc�ditional cnnditio�c.4/requirement.r by the District.
lnspectox: Gcorge Santo� �� �� �
Date:...11-01.�2U07 ................... Ss�nits� Sc.wver �.ocatioa:
:36' .5" I..on�;
5' .5" ncep
9' R/I'I,
cc: ProperL� Uwner
SUPPLYING SANI7ARY SEWERAGE SCRVICES FOR: C1TY OF CUPE:RTINO, PORTIONS OF THL CkTI�S OF SARATOG/+, SUNNYVALE, LQS ALTOS AND
SIIRR�UNI]Ih G UNINCORPQRATED AREAS