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07020106 CITY OF CUPERTINOAmxbo BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 21019 GARDENA DR CUPERTIl\O PLUMBING 07020106 PERMIT ISSUE DATE OWNER'S NAME: CLAUDIA IRWIN 1300 DEItL AVE, STE C 02/22/2007 SANITARY NO. CONTROL NO. ONE: (408) 25: -0618 BUILDING PERMIT INFO ARCHITECIIENGINEER: BLDG ELECT PLUMB MECH n zLICENSED CONTRACTOR'S DECLARATION Job Description LU P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z'J with Section 7000)ofDivision 3 of the Business and Professions Code,and my license is REPLACE WATER HEATER. COPPER REPIPE. WATER MAIN t y in full force and eft 4 )U S )nz License Class Lic.# �i-a r CHANGE. y p Date — Contractor ulV ARCHI S DECLARATI N j a< 1 understand my plans shall be used as public records �� )yU u.in Licensed Professional a OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt Gum the Contractor's License Law for the :no following reason.(Section 7031.5,Business and Professions Code:Any city or county <m which requires a permit to construct,alter,improve,demolish,or repair any structure o'y prior to its issuance,also requires the applicant for such permit to file a signed statementa S Valuation Ft. Floor Are $5000 -?a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Q L t=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or Q 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 FN Number not more than five hundred dollars(5500). 3 2 6 O 8 O 8. V 0 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.). 0 I,as owner of the property.am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a conuactor(s)licensed pursuant to the Contractor's License Law. 0 I am exempt under Sec B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 0 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. a-11avc 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 Warke' pe tsation1nsu�rance.carrier and Policy number are: Cartier._ •C3Z f /— Policy No.: L —�-- CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for anc hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificalc of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z Cn CONSTRUCTION LENDING AGENCY F•r I hereby affirm that there is a concoction lending agency for the performance of R! the work for which this permit is issued(See.3097,Civ.C.) W A Lender's Name =z Lender's Address L O re I certify that 1 have ad this application and state that the above information is [ correct.I agree to comply with all city and county ordinances and state laws relating to rJ U building construction,and hereby authorise representatives of this city to enter upon the W above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against E°,t liabilities,judgments,costs and expenses which may in any way accrue against said City U z in consequence of the granting of this permit. Date 1-1-e'r APPLI AND AND WILL COM WITH ALL NON-POINT Issued b�: CE REGUL —2'z-—O Re-roof: - [--� Signat A can for Dare Type Of Roof HAZARDOUS MATERIALS DISCLOSURE yP Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Codc_,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed. 0Yes 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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? 0 Yes Nu I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building docs not currently have a tenant,that it is my responsibility to notify the occupant of the Date requirementswhi ust met rip or toi_ssuance ficateofOccuZ�� Signatufe of Applicant 2 All roof coverings to be Class"B"or better Owncr r aulhorircd agent Date- CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: amyw COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot: APN 32608083 . 00 DATE ISSUED. . . . . . . : 02/22/2007 RECEIPT #. . . . . . . . . . BSC00000505 REFERENCE ID # . . . : 07C20106 SITE ADDRESS 21C19 GARDENA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER CLRUDIA IRWIN ADDRESS . 21019 GARDENA DR CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM RECEIPT INTERFACE 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 ___ _ ------------- ---------- --- ___ ------- ---------- -- BENERGY PERMIT FEE 1.00 34 .86 0. 00 34 .86 0. 00 BPREPIPE NO OF FIXTURE 1. 00 9 . 00 0. 00 9 . 00 0. 00 BPWHEATER PER HEATER 1. 00 10 .79 0. 00 10 .79 0. 00 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 102 .02 0. 00 102 .02 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------- CREDIT CARD 102 .02 VISA --------------- TOTAL RECEIPT 102 . 02 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- ---- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING Community Development k" 10300 Torre Avenue p ., Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 rUPEkTINO Building Department JOB ADDRESS: � � � PERMIT # OWNER'S NAME: G"�,` -� r,,;y�_ PHONE # 2 > GENERAL CONTRACTOR P� LL, FAX # I am not using any subcontractors: f ='ys_ - Z Si tyre Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI14ESS 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 0-70ZOIO(c REPIPE/SEWEV_S/MAIN SERVICE CUPEI�TINO PERMIT APPLICATION FORM APN # Date: 2 Building Address: Owner's Name: Phone#: Li z- ear lJ TY1 C ntractor: Phone: License#: Conta : Phone: Cupertino Business License#: ,\,e- �()9- y>l Building Permit Info: Bldg ❑ Elect ❑ Plumb Job Description: Residential Commercial ❑ Cost of Project: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING BPGAS Jas 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 :3usiness License BUILDING L?P 6,,A�, --