04090031 CIT4FER
INO
CU ITIUCTQI2INFURMATIONn . ,
N - PERMIT - -
x.�"'-r
BUILDPERMIT NO.04 Q 9(](]31
07;3 SANTA L11121A RID-
OWNEPERMITLSSUEDATE
SANITARY O OL N0.
ARCHBUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
_op LICENSED CONTRACTOR'S DECLARATION
�u 1 hereby affirm Net 1 em IlNURA under provisions of Chapter 9(commencing
Job Dese i
with
Section 7")n(DNWO.30f Ne Boston...nd Profession,C.M.nd my license is
2H INALED
1.1nmmeaneercen. WATER HEATER
j m License Class Lt..M
n Dam Contractor Of T 7j-7 200
�j ARCHITECTS DECLARATION as ,20
�i (1133 I umicmm�d my plans shall he used as public records
o�
Licensed
hereby id from
BUIL®I N
3 OWNER-BUILDER DECLARATION
Eno I hereby.(Sero than 11. exempt from d r Contractor's Co License Lew for the
Eno O which on rima..Permit
t ]anti Business and Profeaim¢Cole:Any city Or county
a�$ which mqulres n e.also res quires the
alter,minnow,demolish Permit t or repair any svunum
poorhsireissuance,aver requires the the inion of for suchmon's Lfilese Lawdstatement
200
Not he is licensed pursuanttothe Common's ndProf 4w(Chepmr9 Sq.Ft.Floor Area Valuation
itt
H O (coma,11 exempt Senfican and th basison 3 of the alleged
exemption.
Any
Code)of
y�$
that he is exempt therefrom and the busts far The allegctl Gumption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 3 412`I97-7ID4iber 0 Q - Occupancy Type
not more Nan five hundred dollars($500).
❑1,as owner of the pmpart,Or my employees with wages as their sole compensation,
will do the work,and Ne awnure is nos intended oronered forsale(Sec.7014,Business
and Professions Codc The COnvacrars License Law docs not apply to an Owner of Required Inspections
propenywho buildsorimpmva thereen,andwho doessuch work himself orthrough his
own employees,provided thmsuch improvements are not intended or offered forsale.If.
howewr,the building or improvement is said within mm year of completion,the owncr-
builder will haw the burden of proving Nat he did not build or improv for purpose of
.in L
1 1,u Owner of the property,am exclusively contracting with licensed contractors to
onmmn the project(See.7044,Business and Professions Code:)The Convector's Li-
come law does not apply to an owner of property who builds or improves Rumor.rad,
who contracts for such projects with a convactor(s)licensed pursuant o the ConmactoYa
License Law.
❑1 ron exempt under Sec. .// /� .B&P C far this reason
T T-WOR�'S COMPEMSATION DECLM TION
I hereby effuse under penalty of perjury andof the fO mg tledamtimes:
W.and will maintain aCeni0csn of Consent to self4tisure for Worker's Compere
salion,an provided for by Section 3700 Of 0e,Labor Code,for the performance Of the
work for which thio permit is issued.
❑1 haw and will maintain Worker's Compensation Insurance,as required by Section
3700 of to Labor Code.for the performance of the work for which this permit is issued. '
My Worker's Compensation Insurance carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
minsection need not hecompli m t if the Permit is for onchundred dollars(Sffi)
or ins.)
I certify that in the performance of the work for which this permit is Wood,I shall not
employ any parson in any manner su a he become subject to the Workers'Compensation
Law,of California.Date -
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Woher'a Compensation provision,of the tabor Code,you must
,J O foMwith comply with such previsions or this permit shall In deemed rewked.
,Z„t► CONSTRUCTION LENDING AGENCY
(~ I hereby aRrm that mere is a construction lending agency for the performance of
ai > the work for which this permit is issued(Sec.3097,Civ.C.)
If]QLender's Name
az Lender's Address
f� I cenify that I haw read this application and soon that the above information is
I2. F correct.I agree to comply with all city and county ordinances and main laws misting to
0 building conswction,and hereby auNotin Wrocentitiwa of this city 10 ennrapon the
W
above-mentioned property for inspection purposes.
(We)agree to an,indemnify and keep bumleas The City of Cupertino against
o-F.t y liabilities,judgmants,costs and expenses which may in any way scout against said City
U z APPLICOUNDERSTANDSof Obc granting ofIAI
ANTAND WILL COMPLY WITH ALL NON-POINT Issued by: Date -
SOURCE REGULATIONS.
Re-roofs
.tort of Applicano'COnvm er n
HAZARDOUS MATERIALS DISCLOSURE ' Type of Roof
Will the applicant or future building occupnt store or handle hanNous material
as dcfrncd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye Z01.
Will the applicant or future building Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I Wearmus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea Nu
I have mal the hammousmatcrialsmquiremoms under Chapnrti.95 of the Calirm,
nia Health&Safety Code,Sections 25505,25533 and 25534,1 understand dutif The building
docs not currently hove a nnnt,that it is my responsibility to notify the acupnt of the
toqul cnvwhichmustWmctpriarmissuancco aCcnifican Of OccnP-cy Signature of Applicant Date
G jjraZa'authorized gem All roof coverings to be Class"B"or better
CITY OF CUPERTINO
1 of 2 PERMIT RECEIPT OPERATOR: quem
COPY # 1
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 34217046.00
DATE ISSUED. . . . . . . : 09/08/2004
RECEIPT #. . . . . . . . . : 26959
REFERENCE ID # . . . : 04090031
SITE ADDRESS . . . . . : 10723 SANTA LUCIA RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MAXINE & JEFF BECKER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3939
RECEIVED FROM . . . . : MAXINE BECKER
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
_____ _____________ __________ __________ __________ __________ __________
BENERGY PERMIT FEE 1.00 34.86 0.00 34 .86 0.00
BPWHEATER PER HEATER 1.00 10.79 0.00 10.79 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 84.02 0.00 84 .02 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
CITY OF CUPERTINO
CA- WATER HEATER � ��oa��
. CUPEkTiNO PERMIT APPLICATION FORM
APN# L `� / Date: 7 `l
Building Address:
Owner' �ime:
�, re.-
Contractor:
T. t4a rd- Ptuoh(Lya3 3 7 y
Contact: _ t �,�r�— Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 0" Mech ❑
Job Description: `l '
Residential B' Commercial14
❑
Cost of Proje 2E
Stcation rapped On Platform Bonded
ew Lo ❑
• NReplacement'
Qty
c Fee ID Fee Description Fee Groan
BPWHEATER Water Heater I Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•