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05050154CITY OF CUPERTINO� BUILDING DIVISION PERMIT CONLRACTOZINFORMATIQ BUILDING ADDRESS: DRAIN DOCTOR PERMIT NO a SOSO1 Si OWNER'S NAME: PERMIT ISSUE DATE ONE SANITARY O. OL NO. ARCHI52=1ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH of 0 0 0 LICENSED CONTRACTOR'S DECLARATION 11 V I hemby afNm Net I am licensed under provisions or Clup tr 9 (commencing lob De:acn tl- EU with Scc ion ]fgp) of Division 3 tribe Business and Professions Code, and my license is 4P iii in full fnroaana effect. ! l' l 3 4 SEWER LINE . License Class Lie. « — Date rat— CUm.tor n(`a: ^ C" Ze Aiei C ARCHITECTS DECLARATION I understand my plans shall W used a public rteord, gt ppp b UILDI1ft Licensed Tonal OWNER-BUILDER DECLARATION pYVp 1 hereby aBifm 1 exempt from Nc Contractor's License Law for the hereby Code: Any city os county odious od following mason. (Section ](131. and o on I.S. construct. altess w ve, de li oc rtpaig any ttmcwm whim rots I.. a alter improve, ccnnil rcS the h conniit t prior m its issuance. also mquime the am for such permiuu fit, s signed mnumem thmpmenccenud pursuant to the provisions of NC COmm Liccnu Law (Chapter Sq. F[. Floor Area Valuat on 7") (cat xem with hecdom,fund of Division of NCegeBusiness ond Professions Code) or that he u Any violation of li and Of buts for the alleged cxmant Ia" 3 erpp Occupancy Type P Y YP 3 L5 b cep to Section T0]L3by vry applicantfor a permit subjects the applicannoacivil Penalty of not more Nan firs hundred dollars (55110). not mom ❑ I, as owner of the property, or my employcn with wegn u their salt compensation, will do the work, and the structure B not buffeted or offend for sale (Sec. 70,4. Business Required Inspections and Professimu rs Code: The Comc w tar, License Law does not apply an owner of property who Wildirmimprow thereon, and who daessuch work himself ortledi his Own employees, provided Nat such improvements an not intended or offered for Wit. IL however, the building or improvement is mid within one year of completion. the owner. builder will have the burden of proving Not he did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with liecrued MmmxdrM to commu<t the project (Sec. 7014. Business and Professions Code:) The Contommr's Lt. cave law does not apply to an owner of property who builds or improves Merton, and who contracts for such projects wit a conlnemr(s) decided pursuant to the Convectors License Law. ❑ I am exempt under Sec. ,B &PC for this rouon _ Owner Date ' WORKER'S COMPENSATION DECLARATION 1 hereby noon under penalty of perjury one of the following declarations: 1 hero and will maintain aCcrdl ©sc of Consent ul6insum for WortrdCUmpcn- satian, as provid, for by Section 3710 of the labor Code. for the perfmmana of the wank for which Nu permit is issued. ❑ I haw and will maintain Worker i Compensation Insurance, as required by Section 3710 of NC Labor Code, for the performance of the work for which this permit is istaed. My Worker's Compensation Insurance carrier and Policy number am: •� Carrier.'2We'iL 5766 C Wn At Polity No.: L 14 I A4 �OS CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if be Permit Is for one hundred dollars (SI00) less.) I certify Nat in the performance of the work for which this permit is issued, 1 shall not employ any Nixon in any manner so as to hccome subject m the WONE Compensation Laws of California. Date Applicant NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should become subject to Oc worker's Compensation provision, of the labor Code, you most fothwith comply with such provisions or this permit shall W deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that these is a convection lending agency for the performance of the work fur which this permit is issued (Site. 3097, Civ. C.) lenders Name Lenders Address ' I Certify Nat I have read this application and suss: Nat the above inrormalion is correct 1 agree to comply with all city and county ordinances and state laws relating tp building convection, and hereby authorim ropmacnmins or this city to enter upon the above- mentioned property for inspection purposes (We) agree 10 save, indemnify and trey harmless the City of Cupertino against Iiabiliticu.judgmcnts, costs and expense which may in any way acme against said City in eonugxnee of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURC��RR�E�..ATIONS. AT Ira C/ S.a ?obi Re -roofs `fi Q SiodiarcofAppicam/GroVica., Dsw HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant Of future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.13, and the Health and Safety cads. Section z5532ba? ❑y. ON. All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant building tau ea or devices which g inruum emit y the Bt nos air contaminants v defined by the Bay Area Air Quality Managcmcm Air Quality all new materials for inspection. District' Disvicl? ❑Yes [:1 NO 1 have read the hazardous m.1cIndsscluio m ods of&, Chapter 6.95 of the Califm- ow Health & Safety Code, Section 255(15.35533 and 25534.1 understand out if de holding Jars not <urremly have a unan4 that it is my responsi hility to nod I the occupant of the rcoimme ch must WonI wissaanccorac<nllcamorOCa2aa<. y 7rYo Signature Applicant Date g PP /Lvu /Llti> 4;r All roof coverings to be Class "B" or better ownertrraathorizzdagent Date • CITY OF UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777 -3228 Fax (408) 777 -3333 Building Department JOB ADDRESS: i(D �'� ,nab µ PERMIT °�oirct OWNER'S NAME/: r I ,n,Pr PHONE # GENERAL CONTRACTOR O5,) 3 1 Ll - /o FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: Owner/ Contractor Signature Date 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 l LY S 5- Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date • Ll Ll sa-M CITY OF CUPERTINO 0505 0) CITY OF CUPERTINO REPIPE /SEWERS/MAIN SERVICE PERMIT APPLICATION FORM APN # PPERM17FFEE Date: Building Address: BPREPIPE Re i e of Fixtures PLUMBING Owner's Name: II!! 1,,�,� Bldg. Permit Fees Phone #: Ind': BPFIXTURE Pbl . Fixture Contractor: �Co.:� 0(+3-0,r Phon t`/°5, 3�o -3o�s License #: 613 yS�S Contact: t'') \ Phone: (L(0) 31b- �16ssy Cu ertino Business License #: p 0Af�I`(f Sewers Building Permit Info: BPSEWAGE Sewage Disposal Bldg ❑ Elect ❑ Plumb I� BUSLIC Job Description: BUILDING 5��� Residential Commercial ❑ Cost of Project: JL/OO O Qty. if Applicable, Fee ID Fee Descrintion Fee C7rnnn PPERM17FFEE Plu bing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPERMFEE Bldg. Permit Fees BUILDING BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING