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07080011 -.-77777777-77-777 CITY OF CUPERTINO g�R1'7� BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 10650 E ESTATES DR TBD - TO BE DETERMINED 07080011 PERMrr ISSUE DATE OWNER'S NAME: PENROD MARTIN & XENA SAM AiR N CONTROL NO. BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH z LICENSED CONTRACTOR'S DECLARATION Job Description 0 r=- I hereby affirm that I am licensed under provisions of Chapter 9(commencing UL withSection 70(1U)ofDivision3ofthcBusiness and Professions Code,and mylicense is DEMO POOL POLLED ALREADY FILLED - INSPECT r in full force and effect. ? License Class Lic.» EQUIPMENT ABATEMENT p Date Contractor _ ARCHITECTS DECLARATION I understand my plans shall be used as public records U �- Licensed Professional a OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law or the ofollowing mason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct.alter,improve,demolish,or repair any structure y prior m its issuance,also requires the applicant for such permit to rile a signed statementc q,Ft.Floor Area Valuation 1 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $1-00 0 O e (commencing with Section 7000)of Division 3 of the Business and Professions Code)or °= drat he is exempt therefrom and the basis for the alleged exemption.Any violation of pN Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6 9 2 5 01'3�'p p NumOccupancy Type ber not more than five hundred dollars($500). ❑1,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 does 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.). I,as owner of the property.am exclusively contracting with licensed contractors to fMnmct 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 Contractor's License Law. ❑I am exempt untie ec &PC for th' reason Owner WORKER'S COMP NSA71ON DECLARATION I hereby affirm under penalty of perjury one of the following declarations: J I have and will maintain a Certificate of Consent to self-insure for Workees Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Workers 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 Compensation insurance tamer and Policy number are: Cartier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This 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,I shall not employ any person in any mannersuhiCct to the wo mpeasation Laws of Califomta D �va iv Applicant -- NOTICE 70 A LICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the labor Code,you must O forthwith comply with such provisions or this permit shall be deemed revoked. rA CONSTRUCTION LENDING AGENCY a I hcrcby affirm that there is a construction Icnding agency for the performance of - the work for which this permit is issued(Sec.3097,Civ.C.) 7 Lender's Name z Lender's Address 0 1 certify that I have read this application and state that the above information is correct.1 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 above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and.expenses which may in any way accrue against said City / z in consequence of the granting of this permit. e-7'-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: _ SOURCE REGULATIONS. Re-roofs Signature of Applicant/Contractor Dare Type Of R�Of HAZARDOUS MATERIALS DISCLOSURE yP 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!;hall be inspected prior to any roofing material being installed. ❑Yes )�No If a roof i:;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 m iterials for inspection. District? V �/ ❑Yes R(. 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 ism nsihility to notify the occupant of the requirementswh' ustbe priorwi pan oraccrtific m Pa^cY- Signature of Applicant Date All roof coverings to be Class"B" or better Owncr or authorized agent Date Community Development xw 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY Of Fax(408)777-3333 ''UPEkTINO Building Department JOB ADDRESS: PERMIT # 1676,5-o E� <5 S 1j2. 0? OWNER'S NAME: PHONE # r��-Zr,Z—�c�3 GENERAL CONTRACTOR: ©c-✓iv 94'Z- FAX # 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 Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Q _ dI-- WO� Owner/Contractor Signature Date CITY OF CUPERTINO 2 ITEMS OF 2 PERMIT' RECEIPT OPERATOR: CathyS COPY # 1 Sec: Twp: Rng: Sub: Bl}:: Lot: APN 361-125018. 00 DATE ISSUED. . . . . . . : 08 '02/2007 RECEIPT #. . . . . . . . . : BS000002235 REFERENCE ID # . . . : 07080011 SITE ADDRESS . . . . . : 10( 50 E ESTATES DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA OWNER PEDROD MARTIN & XENA ADDRESS 10E50 E ESTATES DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4509 RECEIVED FROM . . . . : SEF.VICES, SERVICES CONTRACTOR . . . . . . . : TBE - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBE - TO BE. DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPERMFEE VALUATION 100. 00 83 .16 0. 00 83 .16 0. 00 BSEISMICRE VALUATION 100. 00 0.50 0. 00 0.50 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT : 83 . 66 0. 00 83 . 66 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 83 . 66 10871 --------------- TOTA.L RECEIPT 83 . 66 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO CITY OF CUPERTINO DEMO CUPEkTINO PERMIT APPLICATION FORM � APN# C,Date: Building Address: Owner's Name: Phone#: Contractor: License#: Contact: 611-7 Phone#: Applicant/Contractor: . ding Permit Info: Id Job Description: �mL 1 p. - Residential: �/tj© f Commercial: - * t' Sq-Ft. Floor Area: $/Sq.Ft.: EArchitect/lEngineer: Valuation: zp onstruction: Occupancy Group: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg Permit Fees BUILIDNG BSEISMICOM Seismic Commercial BUILIDNG BSEISMICRE Seismic Residential BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BUSLIC Business License BUILIDNG