07110110 CITY OF CUPERTINO "
BUII:DINS DIV:SION PERMIT ���������������
;.`:: ; : . .. :: :: . . .. .. .: ::
- :.._
PERMIT NO.
BUTLD(NGADDRESS: TOM� S PLUMBING 0'1110110
20358 CLAY ST •
PERMIT LSSUE DATE
.,.VtVER'S NAME:
GLICK JEFFREY S AND PATRICIA P O BOX 362 � 11/19/2007
SANTCARY NO. CON7ROL NO.
PHOtQE:
(408)867-6010
BUIIDING PERMIT INFO
ARCHITEGT/ENGiNEER:
BLDG ELECT PLUMB MECH
� � � �
a p p UCENSED COMRACfOR'S DECLARATION JOU D2SCflpUOf1
� 1 hcrcby sffirm that I am liccnscd undcr provisions of Chaptcr 9(commcncing
� Z� with Sccdon 7000) of Division 3 of thc Busincv �nd Protcssiona Code, and my licensc is RUN GA S L I NE FM MET ER T O F I RE P LAC E
�� y in full force and effec�
� � Licensc CI ��• �
n F� Dam Jl�� - Coauazinr '
ARCHI7'ECl'S DECLA ATION
,� �< 1 undcrsland my plans shall bc wcd as public records
�yU
; u. E' Licensed Pcufcssional
n y � OWNER-BUILDER DECI.ARATION
I hcrcby affirm Uut i am excmpt from thc Conuactor's Liccnsc Law Cor �he
� p O following rcuon. (Scction 7(Yi 1.5. Busincss md Profcssions Ca1c: Any city or county
y_ Pi which rcqui�cs a pcm�it to consuuc[, aitcr, improvc, dcmalish, or repair any suucw�c
prior w i�s iscuancc, alsu rcquires U�c appiicant [or such permit to filc a signcd stamment `; Ft. Floor Area Valuation
' Z<�i ►� � Iicenscd pursuant to thc provisions of thc Convacmr's Liccnsc Caw (C6apicr 9 $117 5
Y F�-� �(commcncing with Scction �000) of Division 3 of thc Busincss and Profcssions C�dc) or
y�� that he is exempt thaefrom and We basu for the allcgcd exemption. My violauon of
Section �031.5 by arty applicant for a pertnit subjecu ihe applicant to a civil penaity of 3 6 9 3 8 0 2��!°�(� Number Oeeupancy Type
not more �han five hund�ed dollars (5500�
❑ I, u owner o[ Uu proper[y, or my employcea wieh wages u ihe'v sole compensatlon,
w iUd o w e workanduwsceuctu�eisnotinten�dorof[uedtorsalc(Sa.�o 44 .Bus�ness Required Inspections
and Peofessiona Cade: The Conuactars Lianse Law dacs not sppty tu sn rn+mer of
prop�ny q bui�da a improves �herean, and who does sucA woric himself or through hia
own employces, provided �a� such improvemrnlv are not in�ended or otfered for sala I[,
6owever, the building or improvement is sold within o� year of compleGon. �he ownu-
builda wiR have ihe burdui of proving �Aat he did not build or impcovc for porpose of
sak.).
Q I. u owner o[ U�e property. am eaclasively conuacting with liansed rnnuactors m
conswct �he project (Sec. 7044. Business and Professions CodeJ The Convactor's Li-
ccnse Law does not spply w an owner of property who builda or improves iheceon, snd ,
who conuac�s for such projects wi�h a conuactor(s) licensed pursuant to We Contnctor's
' rense I.aw.
1 am uempt under Sec. . B dc P C for �his tcason
Uwner Da[e
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalry of peryury one o[ the fallowing declarations:
❑ I hsae and will mainuin a CcrtiGptc of Consent to xlf-ineure for Workcr's Compen-
sarion, u providcd for by Secuon 3700 of �he Labor Code. [or the perfarmance of the
work for which �his permit is issued.
❑[ havc and will mvintain Workcr's Compensation Insurona, u mquired 6y Scction .
3700 of �he Labor Code, for the performana of 1he worlc for wbich �his permi� ia iuued.
My Workers Compenaslion Insurance carticr and Policy number arc:
c�;u''tur Qf� lnS��Wh. r�Kyxo.: C14iSZ7y�
CERTIFICA'fB OF EMPCION FROM WORKERS'
COMPENSATION INSURANCE '
(I'his sxtian ued irot bc complctcd i( Um permit is for onc hundred dollars (S Ia0) .
or Icss.)
I ceniCy that in thc performa�rcc of �hc work fw which this permit is issucd, ! slull not
omploy any person in any manrrcr so u W bccomc mbject to Ihe Workcrs' Compcnsadon
Laws of Glifomia Datc
Applicant
NOTICE TO APPLICAM: If, aMr making �is CcrtiGcatc of Faccmption, you should
bccome subjcct a thc Worlccr's Compcnsation provisions of thc lalwr Cadc, you must
� O forthwith comply wi�h sueh provisions or this permil shall bc dccmcd n.woked.
� ""' CONSTRUCTION LENDING AGENCY
[-~.� ► I hemby affirm Uut thcre is a constnxtion knding agcncy (or �hc perfortnancc of .
(Y, � ihe work for which �his permit is issucd (Scc. 3097, Civ. CJ
W Q Lendcrs Namc
] z l.cnder's Addicss
() � [ cenify tha� I have read �his application and siatc ihu Ihc above informadun is
w � co�c� I asrce to comply wiUi �II rity and county ortfinances md sute laws relaune m
� U building consvucaon, snd hereby aWhorix ccpresenistivcs of Ihis city W cn�r upon 1hc
� W alwve-menuoned prtapcnyforinspccuan purpo.ses
a (Wc) agree to save� indemni(y and kecp humlest Ihe Ci�y of Cupertino ogainst
�� liabilitiu, judgmcnts, cosu and expenses which may in any way accruc agains� said City
V� in consequencc o[ the granting of �his permi� Date
►� APPLICANT UNDERS'TANDS AND W1LL COMPLY WITH ALL NON-PO1NT Issued by: �-��
SOURCE R�GULATIONS.
��f �>,�,�, ' �l�/y/n2 Re-roofs ��
Signature of ApQlianbCon wr �e T of R � �f
HAZARDOUS MATERIALS DISCLOSURE }��
�l1 ihc applicant or Cutwe building occupant storc or handlc hanrdous ma�crial
kfincd by �he Cupenino Municipal Codc. Chaplcr 9.12, and the Hcalth and SaCcty
_„� Scction 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
�y�y �No
Will tAe applicant or future building occupant use eyuipment or devices which
If a roof i: installed without first obtaining an inspection, I agree to remove
cmi� haiardous nir conuminants u dcfincd by the Bay Area Air Quality Managcmcnt all new m; �terials for inspeccion.
Disuict?
❑Ycs �Nu
1 havc read �he hvud�ws ma�crials requimmcnu undcr Chaptcr 6.95 of �hc Califor-
nia Hcalih & Safcry Cade, Sections 25505, 25533 and 25534. f undcrsund thu iC du building
daes not curren�y have a mnan6 Ihat it is my responsibiliry to notiCy drc occupant of thc
rcyu' ��� Wn��n m� x�� �;a�w;��� ore c�r�� ar o�N��r. Signature �f Applicant Date
,� � f ���--��-�t •� ���pQld� All roof coverings to be Class "B" or better
Owncr or autharized agcnl
o�r�ori�
��
CITY OF CUPERTINO
REPIPE/��;��r�����/MA�N SERVICE
CUPE�TINO PERMIT APPL[CATION FORM
APN # �J VJ� .,,�� � �q , C� (.� Date: ( � /��d��
BuildingAddress: . � ` CU � r' `y �� �,,� � 5 ���
'20 3� C I a 5�1- r-e �� ��i
Owner's Name: Phone #:
��-f� `�+ �Gi� �� I�� � �(�.S'lZ3
Contractor: Phone: License #:
ICm�i �'Pl��mbi Yl � $c��l '(�GI C� y� C�$�
Contact: � Phone: Cupertino Business License #:
C-stc� � � C h Y 1 S� r'�S-� n $��� �(pC) I U Q� Y y
Building Permit Info:
Bldg ❑ Elect ❑ l'lumb
Job Description:
fZu n G a s I � r� e-�rz�,�, rr►-� - -�e. r -�r'r�e p I a c�e ,
Residential �] Commercial ❑
Cost of Project: � , / � � a �
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE B ldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
( PPERMITFEE P: umbing Permit Issuance PLUMBING
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 (;UPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ....... 369:38029.00
DATE ISSUED.......: 11/:L9/2007
RECEIPT #.........: BSO�)0003283
REFERENCE ID # ...: 071L0110
SITE ADDRESS .....: 203�8 CLAY ST
SUBDIVISION .......
CITY .............. CUP�RTINO
IMPACT AREA .......
OWNER ............: GLI�K JEFFREY S AND PATRICIA A
ADDRESS ........... 203�8 CLAY ST
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4403
RECEIVED FROM ....: GAIC, E CHRISTENSEN
CONTRACTOR .......: CLA�KE, JOSEPH M. LIC # 10044
COMPANY ..........: TOM'S PLiJMBING
ADDRESS ........... P O BOX 362
CITY/STATE/ZIP ...: SARATOGA, CA 95071
TELEPHONE ........: (408)867
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----
BPERMFEE VALUATION 1,175.00 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 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 129.35 0.00 129.35 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 129.35 � VISA
---------------
TOTAL RECEIPT : 129.35
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
¢.° Community Development
`� �' � � 10300 Torre Avenue
;�; � i „ �
.�= • Cupertino CA 95014
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
CUPEt�,TINO
Buildin De artment
JOB ADDRESS: PERMIT #
-�� �3 �-� c � �+-�-�t ��u �� F-ta ; ��� �rs�y � � l � � � � r
OWNER'S N : ., j � ' � P�� C ' C PHONE # �; � � - - p
GENERAL CONTRACTOR: "i'c1m' S j7 FAX # � � 3-- �� 2
I am not using any subcontractors: - u� f ,'�i.v.,�;� :���� � � C f
Si;nature Date
Please check a licable subcontractors and com �lete the followin information:
SUBCONTRACTOR BUSIrJESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
IIectrical
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
Owner/Contractor Signature Date