06080220 CITY OF CUPERTINO r 177( m� ' 4e.d na xas'rn °
BUILDING 0IVISION PERMIT 'C-0NTRA.CTC,,,"NF4RMATIQIY $:
9UIlDINC ADDRESS: CUPERTINO PLUMBING rFRMIT No.06080220
21841 ALCAZAR AV
'NER4S NAME: PERMrr EVA DATE
CINDY WINSLOW 1300 DELL AVE STE 08/28/2006
SANTARY NO, CONTROL NO.
(408) 253-0618
ARCHrrECT/ENONEER: BUILDING PERMIT MFO
BLDG HECr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Iberrbr.fBm".T.mlieereed.rtoorp�oChWtor9eramm=„alnS Job Description
" MI So<000 TOWl of DMd..3 or the Budlm.nd Pmfrsslom Code.anld my lk.b
Iia infnBR
fo , er 3�
odREPLACE WATER MAIN
� Lie ,
ua� a �19�
F Dan y=1d�`-'c Comrm�or
J ARCHITECTS DECLARATIO
< Imdcv my PWushall be used U Nttic rcrardc
U
LLO ; I irenxd PmfeaddUI
OWNER-BUILDER DECLARATION
<� 1 hcroby alrlrn Wu I am a Pt from We Conbavds L icenv Law for Wr
0 o follwing ro .(Section RD 1.5.Budra "Plofcstiau Code:Any city m county
$ which rogtn.a pcnvit W cavou:l.,Iter.imp..dcmdlah,a mRi,my munmc $1000
1—y Pnor bier iUuance.atm mqui.Wew e aWlfor etrch Permit W Bk,dgnod.1:�< to,tIto uua mdp� tlolhePorlQ .ofthe C«ur>rW"Ur.U, (Ch,pot9 Sq.Ft. Floor Area Valuation
d�m L]W he ildry viNScnian]0ted btoWt nJ lbe-1Bodnct.aMProfe..u,..Codc)or
9 Shu tr B 31.5 b Iitoy i ,M We but,fa bi.1 MA'Pd'to Ann doladan of
s«acro Tml�byk t•pp�^tfv.p=^^II mljea,the.pplkmlw,rnnpavlryw r Occupancy Type
na mare W.n BK kmdmd aalam(sSaGl.
01,Uowner ofIm property.or my eoploy wild npau Weir safe mmprnmlmS,
MU W thew La rd Qe mderure B not ineeMrd or offered for,m(Sm.IDlt,Bdda,• Required Inspections
rnd prMemau Cad=:The Comraear.Limtn law doe ml apply to u owlly of P
Pmprny wln bWldaa improves WurnM1,nd vhaddesuch wvt himsrJf err Wmugh his
own employ=PoWded Wu evW impm.emevu ere M iolended or offered for Ole.it -
h iide,, ii W be oder,of p� gmWe" canrear Of eadpkdm.Wewm.
W iltrr ob hW do.im of proving Wit k did t build or reprove-Pot for ftrp.of _
Ole.}
0 1.U owls of an property.am eaeLW vrJr oaoon ng wild 11-n mrrtrd 5 W
cawracl Wr Project(Sec.7W Bodnty add Pmfesdory Code,)The Coutrrmrs U-
rose law dae.ot a,*In an owner a(pmprny who bullas or odprore Shetmt,and.
wboeoo , far Neh PrOJetVwtb.NnVYm(S)L=G pusUnl blhC CanYYldri
.
w.
C] Ila
❑ un ovdPrtmderSee .Bk PCfa Wu rtamd
Dam V O
WORKERS COMPENSATION DECLARATION /
I bcroby dam under peddty,of P=ry arc or We folW rtg delwaimre (�
1 ba.e rd"I maleWn.cer c al Cnm men
avort V.I.for Wo ,Carper,
vtlat,u pmWdN for EY S��ion 37(](1 of the faRa Code fu the perfamurs of Jr
wort fa whirl AV permit is owed.
0 I have,cid MU mmUin Worlds CWMw,na
ompeman I ,u m ird by Seetian _
3'1(10 or the Labor Code,for We Pceterm.dce Ulhr wart for whdh Itis pmmll d lulled.
My Worlds C an Inamce caries and Policy number ere:
Carticr. EXEMPTION PdlNo: ' Z .
RfIFlUTHO rQNFRO WORKERS _
COMPENSATION INSURANCE '
(Tbb mctlm red not W cadpWlW QWe permh u faonc hmtmdd doeus(SIO
M fell)
1 rmdfy dv1 W She pm y Marne err M work far which t W the w el Tucker I doll ore -
rmploy ury if mu M any madmr m n n beromd>ubjel n Uc Worlva'CaynUWm
Im of Cdifamu.D,Sc
App
NOTICE
ICE TO APPLICANT:If,cornprand p o e ws of err Fumpli Cod,.
y ahauW
bavmeh comp n the W Pro Compeuoaad oMIL ma b the labs Cade,, mssu
,JO faMwilhmmply wild svch pmddamaaw permilslWl he dlrsnd mrotc0.
z "" CQNSfRl1Cr10N LENDING AGENCY
[. I hereby,Rrm WU than B a eovauctdd lending spezY for We porforman¢of
lYi > Wr wnrk for rWh This permit B ivued(Sec.3091.Civ.C)
fat A Isrddr Name '
7 Z sneer.Adamv .. .
U O 1 cmify,W.t I Tuve rad this aPokWa sun Nat We.love inroar".u
ly^ rinnm.1 agree W comply with all aty and roomy ordlU "tern p relating W
OU Wilding eo o tiw.aM bcmby auWarior reprelcwi.es or Ns city W m¢r upm We
res al,d e.men.d hope^y for i......oees.
(We,)'gra mom indcnmify and I oP barrios We City of Cupenieo agdnv
F' N Ii.bllltle,jWgtamLLcosu ud eaT"v.wnich m.y m.ny w,y,arur.gainer oil atr
L) Z, id=mvcqu=tce of Wr I tnting err WU perm11. ,y4
'—' APPLICANT UNOERSTAN WILL COMPLY WITH ALL NON-POINT Issued by
Ac
g�O : Date
SOURCE REGU —a(p
Re-roofs
Slgnalurt erron Us MATERIALS DISCLOSURE Dan Type of Roof
WI applirvua omue WUWng aoeup,unmc orb.ndle h,adaus muaill
da.d by an Cup,N.Mte iripal Code.t3aple 9.12,= d t4 H
ciUIW and Way
am 25532(')' All roofs shall be inspected prior to any roofing material being installed.
pol j a runs(bdding oa:up.um elldiPmcol or deem which
Wdl We aIf a roof is installed without firs[obtaining an inspection,I agree to remove
mail er a dda dr a ,mi D a er by W ear Am,A n zwia �
Me.=a all new materials for inspection.
r•i 7
❑Ye Nd
I base read do h.vudaw re yabennUSWode,ChW wQ95 or She Uifor
M.FInIWhSafmy Coda SB5.25533 and 25534.1 underavd 1Nt i(de:building
ter, ler that I ' Y rcapadd 'tY n miry Ne,RCapml of We
e d n onarO �. Signature of Applicant Date
ow,n m n Dern All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408) 777-3333
SUPEkTINO
Building Department
JOB ADDRESS: PERM�,T rj�D 2 ZlU
g (- l v
OWNER'S NAME: C"Sk PHONE # B. 2y3—cc iS
GENERAL CONTRACTOR / FAX #
I am not using any subcontractors: 2-9 —
S gna a Date
Please check applicable subcontractors and complete the followinginformation
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
/Co a r Signature Date
CITY OF CUPERTINO
�m 1 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35715083 . 00
DATE ISSUED. . . . . . . : 08/28/2006
RECEIPT # . . . . . . . . . : 35786
REFERENCE ID # . . . : 06080220
SITE ADDRESS . . . . . : 21841 ALCAZAR\AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CINDY WINSLOW
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : FRANK CARDIA
CONTRACTOR . . . . . . . : CARDIA, FRANK L LIC # 612
COMPANY . . . . . . . . . . : CUPERTINO PLUMBING
ADDRESS . . . . . . . . . . : 1300 DELL AVE, STE C
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 .
TELEPHONE . . . . . . . . : (408) 253-0618
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- ---- ---- - - -- --- -------- -- ---- - --------- ---------- - ---
BPWSVCS WATER SERVICE 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
----- ----- --- ------- -- ------ -- ------- ---
TOTAL PERMIT 47 . 37 0 . 00 47 . 37 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
________ ____________________________ -------- ----------------------------
103 UFER 106 SEWER & WATER
507 FINAL PLUMBING
.� CITY OF CUPERTINO C�OC7
REPIPE/SEWERS/MAIN SERVICE
�UPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone#:
LA Sbl , I,ti l .5 CS, 23�- 5�U
Co tract Phone: License #:
d� � -1153- Or- t8 C;�4-190S
Conta t: Phone: Cupertino Business License#:
F�"L CG r d i 3U9 -3411
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Er—
Job Description:
Residential Commercial ❑
Cost of Project:" DUU
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 Re i e of Fixtures PLUMBING
BPFIXTURE Pb] . Fixture PLUMBING
/ BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING