07100102 CITY OF CUPERTINO '
BUILDIt:G DIVISION PERMIT ����`��� ����������
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BUILDING ADQRESS: PERMIT NO.
10408 JUDY AVE MICHAEL BASS 07100102 .
PERMTf LSSUE DATE
3R'S NAME:
GARY MOUNTAIN 950 DRY CREEK RD � 11/06/2007
SANITARY NO. CONTROL NO.
PHONE:
(408) 31�6-4422
BUILDINC PERMIT INFO
ARCHi'I£CC/ENGINEER:
BLDG ELECT PLUMB MECH
0 0 � 0
� O p LICENSED CON7RAC1'OR'S DECLARATION JOU DeSCT1pt10I1
V � hereyy aff [m thst [ am liccnacd undcr provisions of Chap�cr 9(commcncing
� wiUiScction70(MI)ofDivision3of�hcBusinessandProfcssionsCodc REMODEL -KITCHEN, HALLS BATH, REPLACE WINDOW
�= y in full force and effec� �� * RE P I P E
j � � Licenx Class
:''� °s `� ARCHITECI'SDECLARA7'lON @ LAiJND:ZY VENT, KITCHEN/BATH DECORATIVE STRIP OF
� o�c < 1 undcrstand my plans shall bc used u public rccords S I DING � CNSTALL A/ C� TANKLE S S WATER HEATER . TH I S �QP�n7/�
�yU `
i p y Licensed Rufcssional /) n �/� �� C' '2 � � /�'� a
y � OWNER-BUILDER DECLARATION /r:_Y�� ✓ `� �� ��
� I herchy a�rm that 1 am cxcmpt Gom �hc Canuactor's Liccnsc Law for thc ,/� `
� 0 0 following rcason. (Scction 7U31.5, Busincss md Profcuions Ca1c: Any city or county O/'_�//''�/ h/7 //�/} ��/�/ n/ n/SS / i'���
y�� which rcquires a permit w consuuct, alter, improvc, dcmalixh, cu rep�ir any swaum (11�J f�( i%' / ( J l YV v WV �.�°-�' �
prior ui i�s issuancc, also rcquires ihc applicant for such permit w file a signcd su�emcn� , jq, FI. FlOOi AI'CS Valuation
_< that hc is liccnscd pursuant to thc provisions of thc Conuactor's Liccnsc Law (Chapicr 9 $ 5 8 6 0 0
� t- �(commencing wi�h Sccdon 7000) of Division 3 of ihc Busincss and Profcssions Cadc) or
y�� that he ia exempt thcrof'rom md ihe buia for ihe allcgcd exempdon. Any violation ot
Section 7031.3 by arry applicant for a pecmit subjects the applicant to a civil penalty af 3 7 510 0 0�!�� Number Occupancy Type
not more than fiw hundred dollars (5500�
❑ I. u owner o[ tHe propecry. or my employees with wages u ihe'v sole compensadon,
will do the work and the stiucwce ia notineended or ottemd torsalc (Sa.7oo4. Business Required Inspections
and Professions Code: The Conuactora License Law does not aPP�Y ��^ �'ner of
property who builda or improves �hercon. and who das such wurk himaelf or through hia CYL �
own employces, providcd ihat such improvements are not imm�ded ar aRered for sala If, /' `
however. U�e building or impeovement u sold wi�hin one year of complcGon. �he owner- � 'z! f' Lf" �/��� �" '�� v `� � �
builder will have the burden of proving ihat he did no� build or improvc far puryose of ���"
sak.). „ I��c�CJ
1. as awner of the propeny. am racclusively conuacting wi�h licensed rnntractors w
conswct ehe project (Sec. 7044. Businas and Professions Cade:) 77�e Coatruwr's Li- /
cense Iaw docs no� spply W an mmer o( propeny who builds or improves thereon, and , �� �
who convac�s for such projects with a canvactor(s) licensed pursuant to �hc Convactor's
Licenae I.aw.
❑ I am exe (�;' � du � S c. , B& P C fw thia n
;� ;•.��h�'Y'� o.� �/ �� d J
WORKER'S COMPENSATION DECLARATION
1 hcccby �rm under penalty of perjury one a[ �he following declarations:
❑ 1 hs+e and will mainuin a Ccnificate ot Conaent lo ulf-iasure (or Workcrs Compen-
sation. u providcd for by Section 3700 of the [�bor Code. [or the pedormarKC of the
wark for which Ihis pertnit is issued.
❑ I Aave and will maintain Workcr's Compensadon Insurance. u squired by Scction .
3700 0[ thc labor Codc. fw ihc pcdormance of the work for which this perniii is issued.
My Workers Compensatian Insurana cartier and Policy number are:
�� Policy No.:
CER7'IFICA7'6 OF EXEMPIION FROM WORKERS'
COMPENSATiONINSURANCE
(This section need not be completecl if ihe permit is for onc hundred doilus (SI00)
or Icss.)
I cenify that in thc performancc of thc work for which �his permit is issucd, l shall not
cmploy any person iarany maonc so u�w,6r�omcsubiect io ihe Workcrs' Compensation
LawsoCCalifa �' ��� �
Applicant .,
N077CE 7'O APPLICAM: If, aflcr making ihis CcrtiCcam of ExcmpGon, yau should
baome subjcct a thc Worker's Compensation provisions of iAc LaAor Codc, yau must
� O foMwiW comply with such provisions or this permil shall 6c dccmcd revokcd.
z "'� CONSfRUCC10N LENDING AGENCY
[— r�-� I hcfc�y amrm �hat thcre is a constnxtion Icndin; agcncy Cor the pecformance o( .
p�., � Uu work fur which ihis permit is iuucd (Scc. 3097, Civ. C.)
W Q Lendcr's Namc
� z I.cnde�s Address
V 0 j ceni(Y �hst I havc read �his application and sis�c �hu thc a6ow informaliun is
w� cortcci. I aya w comply wiih all ci�y md county oNinurces and sute laws relaung to
� U building consuuction, and he�cby authorin mpresenuGves of ihis ci�y w cn�cr upon thc
� W abovc-mcntio�d property for inspection purposes
a (We) agree w save. indcmnify and kecp hamiless ihe City o[ Cupertino against
�„F,� � liabiliuu, judgmcnLS, cos�t and eupcnscs which may in any way acccuc againsl said City
(,) ,'�' in consequencc oC U�c granting of thia permi�. Date ���
�'+ APPLICANT NDERSTANDS AND WILL COMPI.Y WITH ALL NON-PO1NT Issued by:
SOURCE NS. � /� �
-- � � Re-roofs /// (�.
Signaturc of ApplicanUConuac�or � T of P.00f
HAZARDOUS MATERIALS DISCLOSURE YPe
Wi11 Ihc applicant or fuuuc building occupant storc or handlc ha•rardous matcrial
lcfincd by the Cupertino Municipal Code. Chap�cr 9.12. and �hc Hcalth and Sa[cty
:. Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Y� r�
If a roof is installed without first obtaining an inspection, I agree to remove
Will �he applicant or fuWm building accupant use equipment or devices which
cmit hai.ardous nir conuminan�s u ckfincd by the Bay Area Air Quslily Managcmcnt all nevv rr aterials for inspection.
District?
❑ �'a C-�G
1 havc rcad �he hvardous ma�crials requircmcn�c under Chap�cr 6.95 of Ihc Califor-
nia Hcalih & Safcry Cadc, Scc�ions 25505. 25533 and 25534.1 undcrsund ihm if �c building
docs not curtcn�ly vc a �cnan4 �at it is my rcsponsibili�y to nodfy U�e occupant nf thc
rcyuiremcnts � SignatureofApplicant Date
�� �'� �� All roof coverings to be Class "B" or better
Owncr or au�hori�cd agcnl Dalc
CITY OF CUPERTINO
14 ITEMS OF 14 PERMIZ RECEIPT OPERATOR: suew
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 37�10002.00
DATE ISSUED.......: 11/06/2007
RECEIPT #•-••--•••: BSC00003172
REFERENCE ID # -••: 07100102
SITE ADDRESS .....: 10908 JUDY AVE
SUBDIVISION .......
CITY .............: CUF�ERTINO
IMPACT AREA .......
OWNER ............: GAF.Y MOUNTAIN
ADDRESS ..........: 10�08 JUDY AVE
CITY/STATE/ZIP ...: CUF'ERTINO, CA 95014
RECEIVED FROM ....: GAF'.Y L MOUNTAIN
CONTRACTOR .......: MIC:HAEL BASS LIC # 27570
COMPANY ..........: MICHAEL BASS
ADDRESS ..........: 95C� DRY CREEK RD
CITY/STATE/ZIP ...: CADIPBELL, CA 95008
TELEPHONE ........: (4(i8)314-4422
FEE ID UNIT QUANTITY ��MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1.00 34.86 0.00 34.86 0.00
BPERMFEE VALUATION 58,600.00 598.32 0.00 598.32 0.00
BPFIXTURE LTNITS 4.00 36.00 0.00 36.00 0.00
BPWHEATER PER HEATER 1.00 10.70 0.00 10.70 0.00
BREMAIRHAN NO.iJNITS 1.00 10.26 0.00 10.26 0.00
BREMFIXT NO. FIXTURES 2.00 2.40 0.00 2.40 0.00
BREMHEAT NO OF HEATERS 1.00 7.02 0.00 7.02 0.00
BREMPOWER POWER UNITS 1.00 47.96 0.00 47.96 0.00
BREMRECEPT NO. OUTLETS 9.00 10.80 0.00 10.80 0.00
BREMVENFAN NO UNITS 2.00 52.41 0.00 52.41 0.00
BSEISMICRE VALUATION 58,600.00 5.90 0.00 5.90 0.00
EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
MPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
PPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 939.00 0.00 939.00 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 939.00
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TOTAL RECEIPT : 939.00