00030089 ' CITYDFCUPERTINO _ PERMIT NO.
BUILDING DIVISION ' PERMIT CONTRACTOR INFORMATION: ID (00
BUILDINGADDRFSS: ,/ ,f/j l Cr M
/', / SANITARV'NO. APPLICATION SUBMITTAL DATE
06
O GR'SNAME: 'NIC CONTROL#
ON 1l 50 SC,
ARCHITECT/ENGINEER - BOLDING PERMITINFO
y<v .Zy�7y�o
LICENSED CONTRACTOR'SAT
DECLARION
zo�E Ihereby affirm NmlAnn ueen=<dnwerpmvitioMnrcwpmr9(Commencing Job Description
—
with Savcnd A)ofDivision3of rhe Business std Professions ioCade.erdmy,license
in fall forcce aand Ren.
«a< license Class Lic.N
OHO
ARCHTIECTS DECLARATION _
I understand my plans shall h used u public ree0ids
« �iC�ig7 / GQ7
pc LicensN Professional
OWNER-BUILDER DECLARATION
I—Z a 1 hereby¢Kron that I am exempt from the Contraames License Law for the
r O following reason.(SmWA 7031.5,Business and Professors Code:My city«county
na
— which requires A Permit tu co strum,also,improve.demolish,or repay MY nuucmre_ Sq. Ft. Floor Area Valuation
pdonois i.auantt.also squirts Ne applicant for such gamut mfileesigrtd sutemem �V
Net he is cing wi pursuant m Ne provisions 3 rhe Canuhe mmus Liam Law(C oce)
(come is exe pt Securm.on andth basison3 off Alegedssaabd.. Myovi Codc,of APN Number Occupancy Type
rpm he is 31.5 b Nertwm and the basis mo Ne alleged excmptn to My it Plati«t of /G P Y YP
Section 7031.5 car any applicant for•pemdt subjects the applicant w e civil Penalty of �(7 / ^32— Q•Z S/=O K.
pI more than five M1undred dollar(15110). - -
Lasnwn«nrNepropent.nrmre«pinrarwiNwag�.,t�iraoleamp<In,ti«t. Required Inspections
will dothu'ums endo: he Coreisnot imeWM«awdoe msale(ply 7o CA.cooner of -
end Property
iom Code:The Conva ere License law dal era apply m owar of _
property wk builds or improve thereon,and wk rat such w«k nedAhimself ao through
his own employers Wilding
lied r improvement h improvements ere cot uMed«peered for '• I(\//'1/7/J/L—f•/G].
s1e lLhowevwthe vetth b rdnofmuuldwithm one year fample for rhe '
owner kildn will have the burden of moving that M1e dd not k b a improve f«put- -
pose of bait)
❑1 As owner of on,property am I lively cano-rung w'N licensed c«nrxmrs to ,Vi!
c the project ec(S70aa ntad suCade
Buama Profeom )The Comormses Li. -
ceaw«nse law docs not apply m an owner of property who krlds Of imProvOa Jtneon,std
who contracts for such projects with aconvactooO Benue punuanuo the Cummins,
License law.
❑lam el Pt under
Sm. - .Bk PC f«this anon
WORKER'S COMPENSATION DECLARATION '
1 hereby eMo.under pastry ofpcTur,one of Ju following decterauativ:
I have and will WAAW n aCemficas of Comem An self-insure f«Worsees Compen-
Amion.As provided for by Section 3700 of Ne Labor Cade,f«Ne perfomutee of the
work b«which Nis permit is issued. ,
❑1 have and will maintain W«keri Compensation Bsuraus,As required by Section
3700oftheLebor Code,for the pedo.,.fNc work for which this per mit is isruW.
MyWorce,Compe.O..IAmAsce carrier And Policy number art: D M
Cartier: Policy No: - U
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
'(This secsion need not be completed ifthe permit is for one hondrsd"Ims(I I00) MAR i 5 2000 .
«lass.)
Loy Any Naim in my manner of the workfor which Nis pcmullsbroad,s hallson- '
not employ any person in my manna An u m become subject a Ne Wprksn'Compeer-
ution Laws of California.Date � ..
Applicant
NOTICE TO APPLICANT:If,ager making Nis Cerilfcas of Exam,ion,you should - By
become subject to the Wortrr's Compensation provisions a the Lab«Cade,you moat
forthwith comply with such provisions or Nis permit dull k danrtd mv.lv%L
CONSTRUCTION LENDING AGENCY
0 Q Ihertby affirm that there is A c..11.6on lerding agencY booths performance of -
Z. = Ne w«k for which this permit is issued(So.3097.Co.C.)
FLcndees Name
(Yi } Lenders Address -
[S I unify Nat 1 have read Nis applicmion and este that Ne above Wk mutton is
C6sorsa.I agree to comply with all city and county cal unces and sum laws resting to
A7 .Z. building construction.and hereby authorim representatives of this city to enur upon the . -
C.) above-AAcmimmd pmlAmy for inspection Purpose,
Ll. Fun (We)agree fo nave,indemnify end keep harmless Ne Cly of Cupeninp against
C.) liabilidca,jodgments,costs and expenses which may in any way accrue against said City
} W m consequncc of the grunting of this permit. ,
i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINI
VS011RCE RLGULATIONS.
�7� «�
Igttamauf Applicant Contnaor I Date
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicam.,fumnekilding«cup...srortor handle kaetdous ma-ml Re-roofs
At defined by the Cupertino Municipal Code.Chapter 9.12.And the Health And Safety Type of Roof
Coda.Se«mer 25532(.)? / YP
❑Yes Ctta
Will Nc:ppbc.nt or rut.R kild;ng«enp.nt use eq.ipmenr err a<.iee,which All roofs shall,be inspeeted,prior,to'anyy roofing material being:
't hammom air conumivnu aad med by the Bay Ars.Air Quality Mana'numt installed. If a roof is corralled without first obtaining an inspection
iavini I a ree to remove'all'new materials for inspection. Applicant. ,
❑Yn No
I here read the,
Woodcuts maunala n m,menw uMer Chagos 695 ofthe Cali. understands and will comply with all non point source regulations.
forma Health B Safety code,esti no 255115,25533 and 25530.I uMerstand that if the �� � •r� -
oftho d«tan«cumnfiy have the .nl,Natd0'. rtsponsibilirym n«i(Y Nc acupant y 3 �� G.iy.4 ^•
• of the rfx,lm��^=^^u which mus be con poi«missuance oleCmifeme ofpaau�nay. �s .
N— . C 3/fS Signature of ApplicantDate „
ncr or authorized a8em Q Da¢'
All roof coverings to be Class"B"or better
OFFICE -
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE '
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: christya -
Sec: Twp: RnS: Sub: Elk: Lot:36932029.00
INVOICE DATE......: 03/15/2000
REFERENCE ID N ...: 00030089
SITE ADDRESS ..... : 10302 LAS ONDAS WY
SUBDIVISION ...... .
CITY . . ........... : CUPERTINO
IMPACT AREA .......
OWNER ............: DURIL DONALD S AND DORIS J
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3108
CONTRACTOR .......: LIC N
COMPANY ...... ....:
ADDRESS ..........:
CITY/STATE/ZIP ... ,
TELEPHONE ........ :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
_______________ ___ _____
BPWHEATER P 9.99 0.OSHOWE�RR
PPERMITFEE P 35.52 0. 5.52
_________ __________ ____
45.51 0. 5.51
l•ID __ie-- DESCRIPTION =___ _= VOICE IDIPTION
-------- a______ _______________
106 SEWER & WATER 202 UMBING
301 ROUGH PLUMBING 302 ER502 FINAL PLUMBING ENERGY 506
507 FINAL PLUMBING
� MAR 15 2000
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