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06050104 CITY nFC UPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: ABLE SEPTIC PERMIT NO-06050104 19688 VICKSBURG DR PERMIT ISSUE DATE OWNER'S NAME: SCOTT DING 520 REED ST. 05/12/2006 SANITARY NO. CONTROL NO. NE: (408) 377-9990 BUILDING PEAMI-C INFO ARCHIFTECf/ENGINEER: BLDG ELECT PLUMB MECH I p C LICENSED CONTRACTOR'S DECLARATION Job Description V I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing 2z, with Section 7000)of Division 3 of the Business and Profession Code,and my license is INSTALL PROPERTY LINE CLEANOUT y in full force and effect j vn 2 License Cl Lac.# r, C DW Contractor t m .a ARCHITECTS DECLARATION 2 C4 U 1 understand my plans shall he used as public records O l- Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the in O following reason.(Section 7031.5,Business and Professions Code:Any city or county $1600 < 01 which requires a permit to construct alter,improve,demolish,or repair any structure a—m prior to its issuance,also requires the applicant for such permit to rile a signed statement Sq.Ft.Floor Area Valuation -?< that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9 G (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r not more than five hundred dollars($500). I,as owner of the property,or my employees with wages as their sole compensation, will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however.the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)the Contractor's U- cense Law does not apply to an owner of property who builds or irr4?mves thereon,and, who contracts for such projects with a contractors)licensed pursuarg to the Contractor's License Law. Q I am exempt under Sec. B&P C for this reason Owner Dale M.y WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: Q I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. OL 41 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workces Compensation Inwrance carrier and Policy number am: Carrier: -`�'�� C-OM � J Policy No.: U 7 CERTIFICATE OF EXEMPTION FROM WORKERS' I COMPENSATION INSURANCE ('ibis section need not be completed if the permit is for one hundred dollars($100) �. . or less.) I certify that in the performance of the work for which this permit is issued,t shall not employ any person in any manner so as to become subject to the Workcrs'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code.you must 0 forthwith comply with such provisions or this permit shall be deemed revoked. z" CONSTRUC170N LENDING AGENCY t rte- I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) W Lender's Name 0 Lender's Address U 0 1 certify that I have read this application and state that the above information is 41~H correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,*it nis,costs and expenses which may in any way accrue against said City U Z in consequent f the ranti of thi anal. Date APPLICA UN DS D ILL COMPLY WITH ALL NON-POINT Issued by: SOUR U �2 v! �! Re-roofs SigrIVurc orApWcant/C6ntrwuir Date Type Of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. fi ❑Yes []No If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which all new materials for inspection. I emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? Yes ❑No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safcty cede, ti 25 25 3 and 25534.1 understand that if the building does not current) a ten is y possibility to notify the occupant of the requiremcn h et p r of a Certificate of Occupancy. Signature of Applicant Date I L `fit° All roof coverings to be Class"B"or better Owner r u oriz agent Da CITY OF CUPERTINO m 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # : 2 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36910013 . 00 DATE ISSUED. . . . . . . : 05/12/2006 RECEIPT # . . . . . . . . . : 34373 REFERENCE ID # . . . : 06050104 SITE ADDRESS . . . . . : 19688 VICKSBURG DR SUBDIVISION . . . . . . . CITY : CUPERTINO IMPACT AREA . . . . . . . OWNER SCOTT DING ADDRESS . . . . . . . . . CITY/STATE/ZIP . . . : RECEIVED FROM . . . . : ABLE UNDERGROUND CONTRACTOR . . . . . . . : GILBERT, GLEN LIC # 21407 COMPANY . . . . . . . . . . : ABLE SEPTIC ADDRESS : 520 REED ST. CITY/STATE/ZIP . . . : SANTA CLAR.A, CA 95050 TELEPHONE . . . . . . . . : (408) 377-9990 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 ----------------- ------------ - CHECK 59 . 95 3817 TOTAL RECEIPT 59 . 95 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 507 FINAL PLUMBING Community Development } 10300 Torre Avenue °i.n Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY OF UPEkTIN0 Building Department JOB ADDRESS: PERMIT # lye V1& 513 ✓P- DR 0 6,0 So( o cT OWNER'S NAME: !!�Lo ft- ID / PHONE # 2 (' Z GENERAL CONTRACTOR: AX # I am not using any subcontractors: V/Z e Signature Date Please check applicable subcontractors and complete 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 I CLt CITY OF CUPERTINO REPIPE/SES ' 'R /MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM V Date: APN# ,�� i fit,, ` Building Address: I 1 4 pcs., ' // L'JC5 b Vr r__ T)l2, Owner's Name: ` ! _ l� Phone s�Cjt Contractor: Phone: License#: Contact: Phone: Cupertino Business License#: -�r qL k 3 �y y Z 1 L) b 7 Building Permit Info: S �� ®` 0,t< Bldg ❑ Elect ❑ Plumb ❑ Job Description: Residential M Commercial ❑ Cost of Projec : 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 Repipe of Fixtures PLUMBING BPFIXTURE Pblg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING