06080260 (2) CIMWUPERTINO -
BUILDIN DIVISION PERMIT 'XONTRACTORINFORMATION
OUILOING ADDRESS: PERMIT NO.O F)OBO2EO
10715 PENINSULAR AV
OWNER'S NAME: PERMIT ISSUE DATE
DAVID HERRIT
NE:
SANITARY NO. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
100 LICENSED CONTRACT'OR'S DECLARATION - Job Description
U(5j 1 hereby affirm that 1 am licensed under provision of Chapter 9(commencing
;2w with Section 70)(y)of Division 3 ofdo Business and Professions Code.and my us
in fall forrooand wer !y/ 77 5 ADD PROPERTY LINE CLEAN-OUT AT CURB & BACKFLOW
v�x
Urchins Clear Lic.a_z
•F O DateCO
_ ntraclat / S/ (a w f
I 'oj CNOECTS DECDAIRMON
ce� I understand my plan shall W used as public mennts
tyU
'0�
Licensed Professional
OWNER-BUILDER DECLARATION
c c I Wneby.(Rens that 11. cacmpt from Ne Cctures ren License Law for she
❑O following mora(Section IDS LA Basi....aha improve,
dr iron h.or My city or sunny
which mruims a issuance.also 1.re air s the ahcr,M I mSu,h remit fie pair any awmum 2 B O O
fouI y done x)s l ensedpills.requires the inions of fnr Contractor's
noicense..(Clo4nIrn1
< shazWisliccnxJ Pursoam to the provision of she Conuacmr's l.tim^•-law lChapter9 Sq.Ft.Floor Area Valuation
FO
(commenting with rations and of Division 3 of do Business and Prt.Any vi Code)or
3 this io uexempt1.3 bshom(mm and or bun for bj alleged esemptis.Any violation of
Section]031.5 five
any red d all fora permit subjects de applicant to a civil penalty of r Occupancy Type
not more Yon five huntlned drllan(5300}
0 1,u owmr of de propoty,m my cmploym with wages u Noir sok comp=w on,
win as do work.nd,heswnumisnotinmndcdo,.ffemdf.,.M.(Sec.7W,Budnw Required Inspections
and Profession n Cade:The Contractor's Lt..Law dorot apply m m e owner of q P
Property who Wilds orimprow thereon,and whodecssuch work hi ndelfor through his J
own employers,provided than such improvements art not intended oro6ese4 for sale If.
however,de Wilding or improvement u sold within oro year of completion,the owner-
builder will love the omen of proving that k did nos Wild or improve fm purpose of /
sale.).
0 1.as owner of the propeny,w aclwively contracting with licensed snuannrs to
construct she p ajea(kc.7W.assumes and Professions Code:)The Commemr's Li.
come law don non apply to an owner of property who Wilds or improves thrcoo,and.
who contacts for such projects wish a conuauor(s)licensed pususns to the Convector's
License law.
❑lam.temps under See .Bk PCforthisneawn
Owner Date
WORKERS COMPENSATION DECLARATION
40 1 hateby affirm under penalty of perjury one of the following derlantions:
I ha.c and will maintain a Ccnifiste of Cormenuo self insure for Workers Compete
sudden,az provided for by Section 3700 of she Laoor Code.for the perform urs of do
work for which this print t is issued.
0 1 have and will maintain Worlo ri Compensation Insurance,u rerouted by Section
3700 of the Labor Code,for the performhn of Ne work for which this Permit is issued.
My WarkeYS C aha Poliq number,are
Cartier. r-' Polity No.:
CERTIFI ATEOF E ONFR WORKERS'
COMPENSATIONSATION INSURANCE
(This seoinn need not W i,ornpil if the permit is fora..hundred dollars(SIM)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall
employ any person in any manner as as to Wcome subject re the Werecri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Esempnion.you should
become subject to the Worker-s Compcnation provision of the labor Code you mus.
.JO forthwith comply with such provision m this permit sballo dared mvoked.
E7 CONSTRUCTION LENDING AGENCY
(-+ I hereby M.this them u a eMormctinn lending agency,lar the perform.of
tY.�-. Ne were for which this permit is issmd(Sec.309],Civ,C.)
0.W Q lender's Name `
.7 z Lrodres Address
U0 I cmtify that 1 hale send this application and sate thaz the hove information is
LT. F" cen.p.l Agnes,to comply with all city and county eminences;and sum laws relating to
0 U building conswceon,and hemhyauthorim representatives of Nis city to enter upon the
r Lt1 above-memiun.J ss.,us for de.Nuon puryos.a
E~ G (Ws,)agree to save,inJemnily and kap harmless the City o(Cupenino again,
rq inComintern"
ominter "ofth,cram And eapmmamil. may in any why acme against said City
U Z. APPLICANT UN Ehe RSTANDSAranting or nND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ERE ONS.
^T� v Re-roofs
Signature fAppli a,= br Dam
I HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the listsorpi Wilding acevpcntstone m handle haufdon material
u tlerined by 8 c Cupertino Municipal Code,Chapter 9.13,and she Health and Safety
Cole,Section 25532(.)? All roofs shall be inspected prior to an roofing material bei.
41 ❑Yes �a P P � Y g g installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will to air emoato. .ta a Wilding oythesByAeyuipmentmJManaement P g
emir ha'raNnus air conuminanm u JcOncd by dte Bay A.Air Quality Management all new materials for inspection.
D'svicR
❑Yes °r'-'ys(\
I have most she havardo s materials neruimmcnm under Chapter6.95 of the Caliper
M.Health 6r Safcsy Cotic,Sectimm 25505,23533 and 25534.1undcrsand thaziftW Wilding
Jars not curremly ha a tenor Nat in is my responsibility,o notify the..P.,of the
tern / n khustWmeIprixmissnmerracertil' an.y. SignatuTzofApplicant Dale
Owner or atmrriam gen, role/ � All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
•CUPEkTINO
Building Department
JOB ADDRESS- PERMIT #
/0 9/> elo , u 42 x
OWNER'S NAME: ✓ o r r PHONE # .20 5—5-%7 oo
GENERAL CONTRACTOR
I am not using any subcontractors:
ignature Date
Please check applicable subcontractors Tete the following information:
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
•
Owner/Contractor Signature Date
CITY OF CUPERTINO
sm 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32603044 . 00
DATE ISSUED. . . . . . . : 08/31/2006
RECEIPT # • . . . . . . . . : 35856
REFERENCE ID # . . . : 06080260
SITE ADDRESS . . . . . : 10715 PENINSULAR AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DAVID HERRIT
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : RICK JOHNSON
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- -- -------- --- - - ----- ---------- ------ -- -- ----- -----
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- - --- - ----- ---------- - ---------
TOTAL PERMIT 59 . 95 0 . 00 59 . 95 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - -- ------------- - ----------- ------------ ------
CASH 59 . 95
TOTAL RECEIPT 59 . 95
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
CITY OF CUPERTINO
SUM ' REPIPE/SEWERS/MAIN SERVICE
� OF
UPERTINO PERMIT APPLICATION FORM
APN # -3,2–Lo—ca-o44
�_Oa-O44 Date:
:� - 3 - oma
Building Address-
'�/ S Re.v( A-) SL-c /A-eZ AU r'
Owner's N e: Phone#:
Co�tjqcto : n Phone: License #:
< ON .57-10c/ 573-002
Co t: Phone: Cupertino Business License#:
KIJ, C>� D - 7 O
Building Permit Info:
Bldg ❑ Elect ❑ Plumb–K
Job Description: /� 1
ECes,defnpt,raolj � Commercial ❑
ect:
pZ �O6
•
Qty. if
Applicable Fee 1D 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 Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•