07110048 CITY,OF CUPERTINO ` `
BUILDING DtViSION pERMIT �����������������r
_:. , . ,..,_.::
' ; .: ,:: ..:. PERMIT NO.
BUILDING ADDRESS:
10445 BYRNE AVE PLUMBER`3 ON CALL 07110048 .
.VER'S NAME: �� �� DA �
CHUCK CARLE 520 E M( :GLINCY LN #1 2 � 11/09/2007
PHONE: SANITARY NO. CONTROL NO.
(408) 8"�9-0483
ARCHITECT/ENGiNEER:
BUiLDING PERMIT INFO
BLDG EI,ECT PLUMB MECH
� � 0 �
� O p LICENSED CONTRACTOR'S DECLARAT[ON JOU DCSCCIPtlOil
� v U 1 hcrcby �rm that I sm licenscd undcr provisions o( Chaptcr 9(commcncing
_z� wiihSection7000)ofDivision3ofthcBusinessmdProkuionsCodc COPPER ]tEPIPE WTl� LINES, REPLC MAINLINE
'� y in full force and eff � Z C� (�` `
� Z Licensc �� 6 Lic. N
�'-� F„ p Da�c ' Conuxwr
� ARCHITECTS DECLARA77
d Y t undcrstand my plans shill be used u public records
,yU
; u. y Licenscd Ptufcuional
� y � OWNER-BUILDER DECLARATION
,� <� I hcrcby al7irm that 1 am cxcmpt Crom ihc Can�ractor's Liccnsc Law for thc
i p O following mason. (Sxtion 7031.3, Busincss and P�ofccsions CoJc: Any city ar coumy
K,°, Pi which requims a permit co consuuc4 ai�cr. improvc. dcmolish. or repair any swcturc
��� prior tn iLt issuancc, alw rcquims thc applicant for such pertnit w Glc a signcd sta�emcn�
�_ � thai Fie is licenscd pursuant to thc provisions oC thc Conuactor s licensc I�w (Chaptcr 9 ;>q. Ft. Floor Area Valuation
y i- $ (commcncing wiU� Scction 7000) of Division 3 of ihc Busincss and Profcssions Codc) or $ 5 3 6 7
y � that he ia exempt tMaefrom and ihe buis for the allegcd exemption. Any violauon o[
Section 7031.5 by a�ry applicant for a pem�it su6jecu ihe applicant to a civil penalty af -�I�j Nllmber Oeeupaney Type
not more �an fiw hundred dollars (5500). 3 5 7 1 2 � 3�). �� �
❑ I, u owner of ttie pmperty, ar my employcea with wages az the'v solc compensaUon,
will do ihe wodc, and �he stcuctme is notintended or allemd forsale (Sec.7044, Business Re uired Ins eetions
and Professions Code: The Conuactor's License Law da� not spply m an owur of 9 P
propeny who builds or improvea thercon, and who does such work himselt or Uvough hia
own emplayccs, provided that such improvemems ue not in�ended or otCered for sale. If.
hawever, the building or improvement is soid wiihin ane year o[ wmplcGoa, the owner-
builder will have the bmden o[ proving that he did not build or improvc for purpose of
sakJ.
❑ I, as owna of the propeny, am raeclusively conuuting wi�h licensed conuactors a
conswct the peoject (Sec. 7044. Businas and Pro[essions Code:) The Convactor's Li-
cense Law dacs not apply w an owner of properry who builds or improves themon, and ,
who convac�s Cor such projects wiUi a comrutar(s) Iicensed purswnt to We Conuurors
Licenae L.aw.
� 1 am exempt under Sea , B� P C fw this reason
�wner Date
WORKER'S COMPENSATION DECLARAITON
1 hereby �rm under penalty ot perjury one o[ the following declarations:
❑ I hsve and will mainuin a Ccnifiate of Consent to self-insure for Worker's Compen-
sation, u provided for by Section 3700 of the l�bor Code, for �he pedormana af thc
warlc for which Uiis permit is issued.
❑ I havc and wi0 maintain Workcr's Compenariion Insurana, u�cquired by Scction
3700 of the labor Code. Cor tAe pedormmtt of the wwlc for w6ich �hi� pe�mi� is iuued.
My Worker Cor pensa Inwnn c carticr and Poliry number aze: ,
k
Cartier. � Polity No.: ��
CER77F7CATE OF EXEMPfION FROM WO CERS'
COMPENSATION INSURANCE •
(This sectian need not be completed if tle pecmit is forane hundred dollazs (5100)
or Icss.) '
1 cenify thut in thc performancc of thc work for which �his permit is issced, 1 shall not
employ any person in any manncr so az w bccomc subject w U+e Workcrs' Compensatian
Laws of Cali(omia Datc
Applicani
NOTICE TO APPLICANT: lf, aticr making this CcrtiGca�c of Faccmprian, you shoulJ
become subject w the Woricer's Compensation ptovisions of Ihe Laiwr Code, you muu
� O forthwith comply with such provisions or this permit shall be dccmcd �cvokcd.
z �"'' CONSTRUCTION LENDING ACENCY
(- �-�+ 1 hc�cby aftirm dut thcre is s conswction Icnding agcncy for thc perCormance u!
p: � �hc work fur which this permit is issued (Scc. 3097, Civ. CJ
a A L.endcr's Namc �
� z Lenders Address
V 0 1 cenify Wat 1 have tesd �his application and staic �hu Wc abovc informadun is
w� cortcc� I agra w comply wi�h all ciry and counry oNinances and state laws reladng to
� U building consuuction, and he�eby authorin ccpresenutivcs of this cily to cmcr upon ihc
� w ahove-mcn6oned propertyforinspecuon purposes
a (Wc) a�ee to save, indcmnify and kecp harmkss ihe Ci�y af Cupertino against
�� liabiliues, judgmcnls, costs and eacpenses which may in any wsy accrue agsinst said City
(� ,'� in consequence oC Uic granung of Ihis permi� Date // ��
►"'� APPLICANT UNDERSTA DS AND W1LL COMPI.Y WITH ALL NON-POINT Issued by:
SOU REGULA ��
Re-roofs
Signatu o pplicant/Con or ��
H MATERIAI.S DISCLOSURE Type of R�>of
Will �he applicant w C building accupant storc or handlc ha•rardous matcrial
; defincd by the Cupertino Municipal Codc. Chaptcr 9.12, and the Heslth and SaCety
:«�, s�o� zss3zcen `� All roofs s hall be inspected prior to any roofing material being installed.
❑Y� J�u"y
/ v If a roof is installed without first obtaining an inspection, I agree to remove
�Yill �hc applicant or future building occupant usc cyuipmcnt or dcvices which
cmi� harardous air contaminan�s ss dcfincd by �he Bay Arca Air Quslity Managcmcm all new m� iterials for inspection.
Disvicc? �� /�
❑ Ycs � Ny�
�. i
I havc rcad the hva�dous ma�crials requiremcnts uniicr Chaptcr 6.95 a! Uu Glifor-
nia Hcalth & Safc�yCadc, Sixtiiont 25505.25533 am125534.1 undcrs�ind that it ihc building
docs no� curtcn�y havc a tcnan4 ihat it is my responsihility w notil'y Uu occup t of Nc
m uiremcn�swhic metpriorwissuanccoCaCcnil'ica�cotOc pancy.O Signature ��fApplicant Date
Owncr authori�cdagcnl ,� All roof coverings to be Class ��8�� or better
� � I ( c� �? `f �
p �
CITY OF I�UPERTINO
��a REPIPE/�������.:�����/MAIN SERVICE
CUPEI�TINO PERMIT APPL ICATION FORM
APN # Date:
J� `� ( D t 0� �I oy o
Building Address: � � � � � � � � � �
�.�_
Owner's Name: Phone #:
wL c�� �A��S6g
Contractor: Pho � License #:
��Ce �v� �D �— —O�� 3 `�lZ��(
Contact: Phone: Cupertino Business License #:
`�D — �— —O�f�3 ` ��
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ��--�
Job Description:
CO � ¢. E ,
Residential� Commercial ❑
Cost of Project:
J 3� `�-
Qty. �f
Applicable Fee ID Fee Description Fee Group
/ BPERMFEE Bldg. Permit Fees BUILDING
BPGAS G as Pipin System Fee PLUMBING
% PPERMITFEE P lumbing Permit Issuance PLUMBING
�"7 BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE P �lg. Fixture PLUMBING
BPWSVCS N[ain Water Service PLUMBING
BPSEWER S �wers PLUMBING
BPSEWAGE S �wage Disposal PLUMBING
BUSLIC Business License BUILDING
CITY OF C".UPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk Lot:
APN ......... 357"_2036.00
DATE ISSUED.......: 11/�)9/2007
RECEIPT #.........: BSO�)0003202
REFERENCE ID # ...: 071:_0048
SITE ADDRESS .....: 104��5 BYRNE AVE
SUBDIVISION .......
CITY .............. CUP.�RTINO
IMPACT AREA .......
OWNER ............. CHU�:K CARLE
ADDRESS ........... 104�5 BYRNE AVE
CITY/STATE/ZIP ...: CUP�RTINO, CA 95014
RECEIVED FROM ....: PLU�IBERS ON CALL
CONTRACTOR .......: ROBLE DOBKINS LIC # 27158
COMPANY ..........: PLU�IBERS ON CALL
ADDRESS ..........: 520 E MCGLINCY LN #12
CITY/STATE/ZIP ...: CAMPBELL, CA 95008
TELEPHONE ........: (403) 879-0483
FEE ID UNIT QUANTITY AKOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 5,367.00 126.36 0.00 126.36 0.00
BPREPIPE NO OF FIXTURE 7.00 63.00 0.00 63.00 0.00
PPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 230.15 0.00 230.15 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 230.15 #15487
---------------
TOTAL RECEIPT : 230.15
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --------------------
301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY
507 FINAL PLUMBING
, �;,.° .:;
Community Development
10300 Torre Avenue
� • '�;�;- Cupertino CA 95014
Telephone (408) 777-3228
C(TY OF Fax (408) 777-3333
CUPEf�TINO
Buildi�n De artment
JOB ADDRESS: � � � � PERMIT #
�`� � ���`'L�
OWNER'S NAME: Ch,�I� PHONE # b� 6$- 6
GENERAL CONTRACTOR: ���,�. � FAX #
I am not using any subcontractors: ��
Si� e ate
Please check a licable subcontractors and com � e the followin information:
SUBCONTRACTOR BUSIr�ESS 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 u� �l `� (
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
._ ti 9 0
ntractor Signature Date