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CITY OF CUPER'I'INO
. * r '`'" `�; 'F" `
BUILDING DIVISION PERMIT
-€CON TRACIORANEORMATION $°°
pUR.DINGADDRESS:
A.T.C. SERVICE INC
PERMITNO04O4O141
OWNER'S NAME:
PERMIT ISSUE DATE
TUBBS JANE
4
NE:
SANITARY NO, CONTROL NO.
(650)968 -1100
ARCHITECT /ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� Q
LICENSED CONTRACT'OR'S DECLARATION
Job Description
I Mohy affirm that I am licensed under provisions of Chapter 9 (commencing
with Section]WIO fDivision 3 ofibe Business arm Professions Code. and my licence is
re) f
mmnmtme anderrt �v 2
COPPER REPIPE PERMIT LE
Li Class L1ea 51"L
lea"
03
Date Cummmm
ARCHITECTS DELL IO
If a ATN
I understand my plans shall E used public records
APR 3 0 2004
Licensed Professional
OWNER-BUILDER m DECLARATION
I hereby s License Law for me
alarm ohm I rat exempt from the Cnniturs
ll I��
BUILDING
maso Code: Any city or
C county
following (costa (Section ]1131.5, Business andove,
which mquieca a de demolish. s
re construe improve, demolish, nr repair any ,nmmum sher,
e. also
poor ba its licensed issuance, also requires the applicant roe such permit m f Ie s signed mammem
applicant
that
Sq. Ft. Floor Area Valuation
me cngpSesmntmineofDivinmofineCnmmnes sandProfTzw(Chapmf9
tenbeiseingwith Division3 of the Business Professions Cm k7 or
hecioo and th
Nat io is therefrom and me basis for the alleged a Any violation of
exemption. pion.
Section 7831.5
31.5 b any applicant for a permit subjects the applicant to acivil penalty of
pliant to
3 W N3,4uErSerO 0
Occupancy Type
five
not mart than Bvc hundrtd dollars (5500).
0 I, as owner of the property, or my employees with wages as their sole compensation,
will dome work. and the structure, is not metalled or offered for sale (See. 7044, Business
and Professions Code: The Contractor's License Law does nut apply to an owner of
Required Inspections
property who builds or improves thereon, and who does such work himself or though his
tun employees. provided mm such improvements are not intended or offered Tor ale. If,
however, the building or improvement is sold within One year of completion, the owner -
builder will have LM Wrdcn of proving that he did not Wild or improve for purpose of
sale.).
0 1, as e r of the property, am exclusively contracting with licensed contractors to
construct thepmject (Sec. 70,14, Business and Professions Code:) no Contractor's Li.
sonar Law doss not apply to an owner of property who Wilds or improves thereon, and
'
who contracts for such projects with a contractor(s) licensed pursuant o me Contractor's
License Law.
0 l am exem In under See. , B 6 P C for this fcason
Owner Dale
'
WORKER'S COMPENSATION DECLARATION
1 hereby of Tin under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consenuo self - insure for Workers Coddled.
urn, as Provided for by Section 3]00 of the labor Code. for the performance of the
rk for wnich Nis permit is issued.
1C.
I have and will maintain Worker's Compensation Insurance. as required by Section
OO Of the labor Code, for the performance of me work for which this Pemdt is issued.
Worker's Compensation bcsu unee carrier and Policy number am:
mcr: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section used not Meompleted if oM permit is forouc hundred dnlhrs (SIM)
r less.)
1 One ry Nat in the raff ncomme of the work for which this permit is issued. l shall not
employanype 'anymannerso Luke bjecuroMWnr ri Compensation
nrp-t�e P�_�
T.awsof Califo
F!
'
L
NOTICE{.
APPLICANT: If, after making this Certificate E
Ncome
becomes aborodyoushould
subject the Worker's Compensation previsions the
of lde labor you must
vo0e
fonnwith comply who such provisions or this permit anon M deemed rtvnkcJ.
comp y this Permit hal
CONSTRUCTION LENDING AGENCY
I W mhy affirm that mere is a construction lending agency for the performance of
me work fur which this permit is issued (Sol. 3W7, CO. Q
Lenders Name
Lender's Add.
I eanify that 1 ban read this application and some that the above information is
correct. 1 agree to comply with all city and county ordinances and sum laws relating to
building construction, and hereby authorio mprewntativcs or this City to enter upon the
a1mve-mcationed property for inspection
(We) agree to save, indemnify and keep harmless Live City of Cupcnino against
costs which may
may in any way accme against said City
in consequence of re aiand of this Pewitch
in cnnuyucncs of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by:
SOU E R`GULgT1OrIi.
Date
[� —Z Z -0
InN'�( RIJI:i_, V
Re -roofs
'
Sogrincre of ApplicamUCuntracor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will me applicant or future building occupant store or handle hararduus material
as defined by the Commit) Municipal Code. Chapter 9.12, and the Hcalm and Safety
CWe. Section 25532(87
❑Yea ON.
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment
pct s v 4 poem or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
g
ail ha' /mmma air Contaminants as dc0ncd by the Bay Arc. Air Quality Management
all new materials for ins
_Wlicn
P eCIIOn.
OYes 0No
1 have read the Waardio s materials requirements under Chapter 6.95 of me Califon
nia Health &Safety Cmlc, sciences 25505,25533 and 25534.1 undemuad deal iftM Wilding
doe not Currmnly harm a tempt, ma h is my responsibility no noufy me weupan, of the
red menawmm� r9 mapdrrI- issmnceor .cempeamorOccupancy.
_2'2 -0
Signature of Applicant Date
All roof coverings to be Class "B" or hener
wooer or aumml.ed agent Dam
Community Development
10300 Torre Avenue
It � {�' Cupertino CA 95014
Telephone (408) 777 -3228
CITY OF Fax (408) 777 -3333
�UPEI�TINO
Building Department
1
JOB ADDRESS: AL / N L —'
PERMIT # D C- b y D
OWNER'S NAME: ----S-A a 4E ?'J ,c3,;6 S
PHONE #
GENERAL CONTRACTOR
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following informatinre
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature Date
•
0
CITY OF
CUPEkTINO
CITY OF CUPERTINO
REPIPE /SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
o yoyo /�l /
APN # Z
O 4
t
Date: f� .Z r2 O 4
`T
Building Address:
BPREPIPE
Owner's Name:
PLUMBING
Phone #:
BPERMFEE
-A0 e - 0 i3
Qa- 7$ ' 510
Contractor:
Phone:
License #:
TC
Cosa - 4768 -//,100
S24� (. 'ZZ
Contact:
Phone:
Cupertino Business License #:
w.
Sewers
PLUMBING
Building Permit Info:
BPSEWAGE
Bldg ❑
Elect ❑ Plumb
Job D scription:
Business License
BUILDING
Cge
PE
Residential
Commercial ❑
Cost of Project:
0 O
—�U
Qty. if
ADDlicahle Fee TT)
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PPERMTI'FEE
Plumbin Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pbl . Fixture
PLUMBING
BPW S V CS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
Business License
BUILDING
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