06120085 77777777�
CITY OF CIUPERTINO o- :>�. r x-
BUILDING DIVISION PERMIT .-coni_ RA CTORANFORMATION
BUILDING ADDRESS: PERMIT NO,
OWNER'S NAME: E
TRACY HOUS 701 ALDO AVE, STE 43 12/18/2006
7ARCH=��:�:G:INEER-
: SANITARY N0, CONTROL NO.
(408) 234-8134
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0LICENSED COFTTRACrOR'S DECLARATION
Iherebyaffirm NetI am licensed underprovisionsofCMper 9(commencing Job Description
ction7MO)afDivision3aftheSted.andPowlessionsCode.admylicenxu GAS LINE TO METER AND UNDER HOUSE
mrecand cffccL ��Clu,'r1 $ OV ContfM�k�ar1 Vim^
ARCHITECTS DECLARATION
i < I understand my plans shall M=it as public records
yU
'LLo
Licensed Professional
S OWNER-BUILDER DECLARATION
n1 hnmby.(Tran that 1 a.1. acmpl from the fes oactor,License Law for the
o O following..on.(Sccuon IID LS er,Business and Professions Cod,:Any oily or county
•m which requ4ns a permit w mnmuct,,ler,improve,demolish.or repair any structure
prior in its issuance.also requires the applicant forsuch permiuo file a sigod statement
that he is becloud pursuant to the provisions of the Contractor's lJauc Law(Chapter 9 Sq.Ft.Floor Area 1605 Valuation
70
s1-C (commencing with Section 00)of Division 3 of the Business and Professions Code)or
55 94- Nal has is..pt Nemfrors and the basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil Penalty of Number Occupancy
not roam than fiva hundred dallau($500). 35714026 ! P Y Type
Q 1,u owner of the pvpeny.on my employes with wage u Heir sok campewuon,
will Pr Newark.ands,TheCmtsnot License
La does
usa4,Bud1 of Required Inspections
and property
who
Cad,The Cuntramon,License Law dors tel apply lf an rough is q P
property who builds vi improves ch imps and who ar esti,tendo Aimmetedlfor 0uough Lala
own employes,provided that such improvements are not intended mpleti d for sale If,
huilder.Nc Wilding or improvement umid within one Weld of cprovefrNe owacr. -
builder will have Use burden of proving Nu he did not build or improve:for puryox of
sakJ.
❑1,u owner of the prepeny,am exclusively Combined,with licensed mnuanon do
Co.,.,the project(See.70x4.Business and Prof,ssimes Code)re,Conrracmts Li.
Co.,Law des oat apply m an owner of property who build,or improvas thereon,and.
who convects for such project with aeon icmr(s)licensed Foramen to the Contractor's
L en ,mi
❑ladeaempl under See .Bh PC for Nis reazan
Owner.. Data
WORKERS COMPENSATION DECLARATION
I hereby affnd under Penalty of perjury one of the fallowing declarations:
u I bs+e and will William a Certificate of Conseil to delfAmom for WorkcYs Compen.
acarian,as provided for by Section 3700 of one Labor Code,far the performance of the
work for which this permit is issued.
Oy1 Uw and will maintain Workcri Compestadon Iwnna,as mquimd by Sccuon
3700 of the Mbar Code,for the performance of the work for which this permit is issued '
My Warkers Compensation Insurance artier ad Policy number ase:
Cartier: Pus; CLLQu P Policy No, JV&0tZ�yV b )
CERTIFICATE OF EXEMPT10N FROM WORKERS'�
COMPENSATION INSURANCE
Mussecuan .it not W completed if the permit is formic hundred dollars(5100)
or less)
1 certify that in the performance of the work for which Nis permit is issued.I shall not
employ any person in any manner m as u become subject o N,Workeri Compeuaden
Laws of Califomia.Dae
Applicant
NOTICE TO APPLICANT:If,after making Nis Cenifica¢of Exemption.You should
become subject in the WoraeYs Compeuation provisions of o,Labor Cod,you most
.J aZ forthwith comply with such provisions or this permit shall M deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-s�+ Ihcmhy affirm Nat there tsa cmtuucrinn lending agency far theperftom.of
r1. the wurk for which this permit is issued(Sec.3097,Civ.C.)
GQ Lenders Name
z Lenders Address
V O 1 cenify that I have rad Nis application and sum that Ne r brae informasiun is
it, f'^ corm¢.I agree to comply with all city and county oNimmas and Slate law,misting 10
U building convection.and hereby authmriae mprrscnlalivcs of Nis City to enter upon the
F 4 above b enu0oed property far inspection proposes.
Wc)agree to save,indemnify and kccp harmless the City of Cupertino again) _
to bilitia,'udgmens.costs and sexpcores which may in any way accrue against said City
C.1 z APPLI q ce of theUNDERSTANDS
of this permit. r
'-' SOURCE
UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE ULATIONS,
T Re-roofs
Signature AMHl 9C
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building axupeaLstore or handl,havamous material
as dennd by the,Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532(a)7
pY„ m All roofs shall be inspected prior to any roofing material being installed.
Will the,applicant building occupant um If a roof is installed without first obtainingan inspection, I agree to remove
PP B P cyuipmcm or devices which P
tv
ithuNu mmirut uaoair coondcOnd by the Bay Arca Air Quality Managcmcnt all new materials for inspection.
suia?
❑Ya Nu
I have read the harafdams materials requirements under Chapmrb.95 ardor Califon
iia Hcall &Safety Cod,Setians 2SM5.35533 and 25534.1 undersand thm if Ne Wilding
d curly fare a eoant Nu it t my mspomihilitY m nmulj the occupant of Use
m ire u hick mum he mel prior to issuance of a Cwfeae of Occupan
`�L— tI-J Ivo Signature of Applicant Date
Owner Ormthmrivcdage., am All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
f ✓' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
IOUPEkTINO
Building Department
JOB ADDRESS: PERMIT # � —
a\�-I1 ��o� Zob
OWNER'S NAME: PHONE # 6 ci5- k�R'4
GENERAL CONTRACTOR: c R 9-a o1-6K FAX # -I qS- 0 Z 4
I am not using any subcontractors: It too o v
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
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
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35714026 . 00
DATE ISSUED. . . . . . . : 12/18/2006
RECEIPT #. . . . . . . . . : BS000000012
REFERENCE ID # . . . : 06120085
SITE ADDRESS . . . . . : 21871 DOLORES AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : TRACY HOUS
ADDRESS . . . . . . . . . . : 21871 DOLORES AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : SPEEDY ROOTER PLUMBING LIC # 23086
COMPANY . . . . . . . . . . : SPEEDY ROOTER PLUMBING
ADDRESS . . . . . . . . . . : 701 ALDO AVE, STE 43
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95054
TELEPHONE . . . . . . . . : , (408) 234-8134
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
----- ------------- ---------- ---------- ---------- ---------- ---
BPERMFEE VALUATION 1, 605. 00 83 .16 0. 00 83 .16 0. 00
BPGAS OULETS 1. 00 5.40 0. 00 5 .40 0 . 00
PPERMITFEE FLAT RATE 1. 00 38.37 0. 00 38 .37 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 126 .93 0. 00 126 . 93 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 126 . 93 386
---------------
TOTAL RECEIPT 126 .93
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM 0 �IdOT
APN # 5 j _ Date:11A \'J 0b
Building Address:
\911 aJow4.� L►C(Q
Owner's Name: Phone#: D`%4
-TW,4L,J (0-17 -pS o-1
Contractor:' Phone: License #:
SPIFuOH I
Contact: OXAO. Phone: A 5_ Cupertino Business License#:
geNa
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:Residential Commercial ❑ _
Cost of Project:
ItoOS
•
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 Dis osal PLUMBING
BUSLIC Business License BUILDING
•