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07090179 CITE'OF CUPERTINO T BUILDING DfvISION PERMIT C�`►�TR�►� Q y '`i� © ' BUIL ING ADDRESS: PERMIT NO. �84 S BLANEY AV CHAIYAR SIRIPOKE 07090179 OWNER'S NAME: PERMrf ISSUE DATE CHAIYAR SIRIPOKE 09/26/2007 )NE: SANITARY NO. CONTROL NO. BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 0 0 00 LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing z Lowith Section 70(10)of Division 3 of the Business and Professions Code,and my license is REP LAC I t f G WATER HEATER h y in full force and effect. h z License Class Lle-# t—in Date Contractor lit.a ARCHITECT'S DECLARATION i a< I understand my plans shall be used as public records )aU 'U.ti Licensed Professional h OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the "Q0 following reason.(Section 703 1.5,Business and Professions Code:Any city or county Pu� which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft.Floor Area 900 Valuation e.t (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type not more than five hundred dollars(5500). 3692700, ❑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 Re uired Ins ections and Professions Code:The Contractors License Law does not apply to an owner of q p properly 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 Contractor's Li- cense Taw 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 underSe B&P C for this reason Owner Date WORRgE5AMPSWATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 1 have and will maintain a Certificate of Conscnt 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. ❑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 carrier and Policy number are: Carrier: Policy 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,1 shall not employ any person in any manner so as co Workers'Compensation Laws of Californa. a itc Applicant NOTICE TO APP C 1 a king this Certificate of Exemption,you should become subject to the Worker's C mpensation provisions of the Labor Codc,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 C>~✓ the work for which this permit is issued(See.3097,Civ.C.) lra A Lender's Name Z Lender's Address U O 1 certify that I have read this application and state that the above information is 0--4 correct.I agree to comply with all city and county ordinances and state laws relating to C U building construction,and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against fn liabilities,judgments,costs and ex sets which may in any way accrue against said City r V z in cmnseghhcnce of fru of.- tic Ih permit Date r,, /- APPLICANT UN RST N A D�WlCOMPLY WITH ALL NON-POINT Issued by —LUG%) SOURCE REGUL TION i Re-roofs Signature o(AppliaDam HAZARDOUS Type of Roof HAZARDOUS MATERIALS DISCLOSURE 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 Will the applicant or future building occupant use equipment or devices which If a roof i;installed without first obtaining an inspection,I agree to remove .nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes ❑No 1 have read the hazardtw materials requirements under Chapter 6.95 of the Califor- niaHcalth&Safct C to 25505.25533 and 25534.Iunderstand that ilthe building docs not cu y a ant that it is my responsibility to notify the occupant of the rcquircments hIC st nor to issuance of a Certificate ofOccu Signature of Applicant Date kr� Owner or authon. age Date All roof coverings to be Class"B"or better CITY OF CUPERTINO WATER NEATER CUPEkTINO PERMIT APP]-JICATION FORM APN# 11 p. Date: Building Address: So Owner's Name: Phone# Contractor: Phone# O W NOZI a u i Llpw- Cupertino Business License# State License# Building Permit Info: Bldg Elect (jlu_mb) Job Description: p�MA U" N(e vVyrj;�.-L Residential ( Commercial F-1 Cost of Project: Strapped On Platform Bonded Ifl— New Location X Replacement Qty. if Applicable Fee ID Fee Description Fee Group PRWHEATR [Zesidential Water Heater/Vent BUILDING PCWHEATR -ommercial Water HeaterNent BUILDING PPERMITFEE Plumbing Permit Issuance . PLUMBING TRAVDOC Travel &Documentation Fee BUILDING BUSLIC Business License BUILIDNG VL 4S 6' SETBACK v)CCNC PAS --- <., SETBACK tucT �s� I (E) 1—:TORY HOUSE v^ . 063 S.F- I w L uw.. I2%M14 (E) GAS. �. z. METER L a NI:W 1 STORY ADDITION �' �/ � l ' — •. REMOVE(0) TREE CALIF. WHITE PINE RJT a N, VV 2—CAR GARAGE I 482SF ,M 00% PAD 50,F LoBkK 6' _ , —,— ---- (N)(`CNC WAi K qq a ! ,CONC G LVE REN C VE (E) TREEt �t r c K , ._. y hl S 1 CAL —. WHITE PINE c) c, N I (E)LANDSCAPE - &'K' f (L)SIDEWALK , W J (E) LANDSCAPE oo , ` e 107 � WYv ♦�1 � r s zt k k r S. BLANI_EY AVENUE s, aaw.s, CITY OF CUPERTINO PERPIIT RECEIPT OPERATOR: patg 3 ITEMS OF 3 COPY # 1 Sec: Twp: Rng: Sub: 31k: Lot: APN 36927002 . 00 DATE ISSUED. . . . . . . : 09000000067 RECEIPT #. • • • • - " 07090179 REFERENCE ID # . • • SITE ADDRESS . . . . . : 884 S BLANEY AV SUBDIVISION CUPERTINO CITY . . . . . . . . . . . . IMPACT AREA . . . . . . • OWNER . . . . . . . . . . . . : CHAIYAR SIRIPOKE ADDRESS . . . . . . . • • • CITY/STATE/ZIP RECEIVED FROM CHAIYAR SIRIPOKE CONTRACTOR LIC # *OWNER* COMPANY CHAIYAR SIRIPOKE ADDRESS . . . . . . . • • • CITY/STATE/ZIP TELEPHONE . . . . . . . . UNIT QUANTITY AMOUNT PD-TO-DT THIS REC -_NEW_BAL- FEE ID ---------- ---------- _ ------ ---------- - 40.79 0. 00 -- ------- 1. 00 ----40 .79 0. 00 PPERMITFEE FLAT RATE 1.( o 24 .48 0.00 24 .48 0.00 PRWHEATR UNIT'S 0. 00 40.79 0. 00 1. (i0 40.79 ______ ------- TRAVDOC FLAT RATE ---------- --- 106 .060. 00 0.00 106 .06 TOTAL PERMIT : METHOD OF PAYMENT AMOUNT -- _ REFERENCE NUMBER ____ ______ --------------- CHECK 106 . 06 #103 TOTAL RECEIPT 106 . 06 ----_---- VOICE ID DESCRIPTION VOICE ID DESCRIPTION ____________________________ -- ------ 506 GAS TEST 502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate fami.y (parent, spouse or child) will perform: A All the work authorized by this permit B — A portion of the work C — None of the wor.c If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A _ All of the work B — A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be erformed ll 3. I will utilize unlicensed person(s) other than my immediate family eo perform rversede a A r portions of the authorized work. I understand that I maybe an employer (se Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Address/Ci.y Phone Number Type of work to be Person/Firm erformed ..................... . ............................... I fare der penalty of perjury that the above is true and correct. I have read and understand the -declare unwner-Builder Information (7UL d _ _ Date: Property Owner's Signature: Q� Permit# Job Address: `� '— `� An changes to the information provided on this form shall be submitted to the Ci of Cupertino Build Department. CO 30 0�0 T° to95014 Lupe p8) Teleph�ax(408)111"3333 end circ of ,uildl�l pE�IT .�?_.� ,. INo gESS� �� ✓ Lw- JOB ADD to �a OwNEg, L CONT' R� oration. CENSE # GEl�gP' bcontractors' Si to the fou°w'n $USINESS LI not using any st1 rs and c Dm le N�iE 1 am orttracto BL SIN1 S a licable subc QR Please cheSUBC�N�gA ork Cabe ts CernentFinisY►ing El��cal ExcaV .On Fe1`cing Carpeting �oor'r`g• wood Glass / Gla-'ng T�leating emulation ndscapir►g 1,ativng masor►ry arnental Sheet Metal I,ainting � wallpape Paving Plasterij S Plumbing goof isig Septic'Tar►k �., Sheet Mem Date Sheet Rock Zile Slgr'ature ane ontrac r