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07090112 CITY OF CUPERTINO I BUILDING DIVISION PERMIT IBU(LDrdMESAINSWORTH DR NEW STRUCTURE PLUMBING INC PERMIT 07090112 OWNER'S NAME: PERMIT ISSUE DATE LEE SHEILA S AND LO DANIEL M P OBOX 111143 09/18/2007 jNE: I(408) 364-2143 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �O p LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description z Lu with Section 700x0)of Division 3 of the Business and Prof Cam, y licen�c is WATER MAIN REPLACEMENT. y in full force and efteCR ?N2; Licen I L-'-" Ste' Lie.S 3 F C Date Contractor Lu RCHITECTS DECLARATION w U 1 understand my plans shall be used as public records •A. o y Licensed Professional 15,J ONER-BUILDER DECLARATION J< I hereby affirm that I am exempt from the Contractor's License Law for the .00 following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure z y prior to its issuance.also requires the applicant for such permit to rile a signed statement =o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor AreaI Valuation e t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i that he is exempt therefrom and the basis for the alleged exemption.Any violation of $1700 Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of 3 2 6 4 6 0 0 2 �Number I Occupancy yp not more than five hundred dollars($500). Type ❑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 and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections 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 Contractors Li- cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. ❑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: ❑1 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. ❑I 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 Worker s Cy�rens o su c airier and Polity nu-'gbcr Cartier: 4'Tiir prey No.: c; 1 KATE F ON FROM WORKERS' CON 4 ATION INSURANCE (This section need not be completed if the permit is for tine 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'Compcnsation Laws of California.Date Applican, NOTICE rO APPLICANT:If,after making this Certificate 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 CONSTRUCTION LENDING AGENCY [-+ + I hereby affirm that there is a construction lending agency for the performance of Ri> the work for which this permit is issued(See.3097,Civ.C.) [z7 Q Lender's Namr Z Lenders Address U C) I certify that 1 have read this application and state that the above information is rJ Ucorrect.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the a above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against t� liabilities,judgments,costs an penses which may in any way accrue against said City U 7�. in consequence oC the g g of this permiL "a APPLICANT UN STANDS AN COMPLY WITH ALL NON-POINT Issued by Date SOURCE REG ATIO T I Re-roofs Sig of ApplicantIContractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof 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. E] o No S4 Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,.1 agree to remove emit hazardous air contaminants as dcftncd by the Bay Area Air Quality Management all new n-aterials for inspection. District? Q Yes ❑No I have read the hazard ateriats requirements under Chapter 6.95 of due Califor- nia Hcalth&SafetyCotye ons25505.25 534.1 understand that if the building does.not currently a tenant,th h responsibility to notify the occupant of the requrements w ' must be anee of a certificate ofoe p� gnature of Applicant Date �" " �1 4:7� All roof coverings t O er or authorized agent Dare O gS o be Class"B"or better CITY OF CUPERTINO 2 ITEMS OF 2 PER=' RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bl}:: Lot: APN . . . . . . . . . 32E46002 .00 DATE ISSUED. . . . . . . : 09/18/2007 RECEIPT #. . . . . . . . . : BS000002679 REFERENCE ID # . . . : 07090112 SITE ADDRESS . . . . . : 104:80 AINSWORTH DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LEI' SHEILA S AND LO DANIEL M ADDRESS . . . . . . . . . . : 104:80 AINSWORTH DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1045 RECEIVED FROM . . . . : LEON FRIDLIG CONTRACTOR . . . . . . . : LEON FRIDLIB LIC # 26052 COMPANY . . . . . . . . . . : NEW STRUCTURE PLUMBING INC ADDRESS . . . . . . . . . . : P OBOX 111143 CITY/STATE/ZIP . . . : CALIPBELL, CA 95011 TELEPHONE . . . . . . . . : (408) 364-2143 FEE ID UNIT QUANTITY LMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- --•-------- ---------- ---------- ---------- BPWSVCS WATER SERVICE 1. 00 9 . 00 0. 00 9 . 00 0. 00 PPERMITFEE FLAT RATE 1. 00 40.79 0. 00 40.79 0. 00 ----------- ---------- ---------- ---------- TOTAL PERMIT 49 .79 0. 00 49 .79 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 49 .79 VISA --------------- TOTAL RECEIPT 49 .79 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 0-7 0q o FA C 11F REPIPE/SE k li Ll -_ /M SIN SERVICE k(i CUPEkTINO PERMIT APPLICATION FORM APN# Date: 3c;�to 14 o 0,;� , c) 1911-9 /-7 Building Address: Owner's N Phone#: 17,6 M, Contractor, Phone: License _: Cont ct: Phone": Cupertino Business License#: e- - 4 Building Permit Info: Bldg ❑ Elect ❑ .dumb Job Description: ?,Z, Residential �r Commercial ❑ Cost of Project: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE I R.dg. Permit Fees BUILDING BPGAS l Gas Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE R,-.pipe of Fixtures PLUMBING BPFLXTURE Pblg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING Community Development 10300 Torre Avenue st Cupertino CA 95014 Telephone(408)777-3228 CITY of Fax(408)777-3333 -UPEI�TINO Building Department JOB ADDRESS: /� PERMIT # OWNER'S NAME: sue,' Le� PHONE # G�� /�3 GENERAL CONTRACTOR:111e,41 # I am not using any subcontractors: 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 ILandscaping I Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering (� Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date