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'CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
iCONTRAGTOR,INk O�RMA.TION 5
BUILDING ADDRESS:
AAAA —DRAIN PATROL
PERMIT NOO50 %0004
10386 AL12INE
OWNER'S NAME:
PERMIT ISSUE DATE
DISELA LAZAROW
2400 LINDBERGH
Q7/01/2005
ONE:
SANITARY NO. CONTROL NO.
(408)989 -6005
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O
LICENSED CONTRACTOR'S DECLARATION
hereby licensed Chapter 9
OO
Job Description
1 affirm that I Am under previsions of (commencing
with Section7q )of Division3ofthe Bustiv..and ProfcWam Code.andmylicenseis
in Di«l°ci�nderc «t. Lie.a�- ZZIZ�6
GAS PIPE FOR STOVE
yl�
DatO Contractor
AR mall Wuse DECLARATION
1 understand my dull he used u roeurtls
plans public
Licensed Professional
OWNER-BUILDER DECLARATION
nlrnat'a License Law for the
1 hereby affirm that 1 am exempt from du Co or
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(�`�
following moon. ( Secuon 713 L5, Business and Professions Code: Any city or county
which requires a Permit to construct. alter, improve, demolish. or repair my structure
V
`
prior to is issuance, alsu requires the applicant for such permit to rile a signed statement
that he is licensed pursuantt to the previsions of the Contractor's License Law (Charter 9
Sq. Ft. Floor Area wd �qu /Valuation
(commencing with Section 7000) of Division 3 Of the Business and Professions Code) or
that ke u exempt ft.fmm and the basis for the alleged eaemptina. Any violatinn of
\
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
9
Occupancy Type
not more than five hundred delta. ($500).
D h AS owner of the property, m my employcu with wages AS their sole compenation,
will do the worc and the awetme is not intended or offered forage (Sec.7)44, Business
And Professions Cox: The Conuactors Liarve Law dues trot apply to an owner of
Required Inspections
property who builds or improves Ihemon. and who does such wed himself car through his
own employees. provided that such improvements Are not intended orofrered foraale. If,
however, the building or improvement is sold within one year of completion, the Owner-
builder will have the burden of proving that Im did not build or improve for purpose of
ASIA I.
D 1, as Owner of the property, am exclusively contacting with licensed contractors to
convect the pmjcct (See. 7(44, Business and Professions Code:) The Contractors Li.
cove law does not pply to an owner ofpmpeny who builds or inform demon, and
who cOnmets for Such projects with aeontractor(s) licensed pursuant to the Contractors
License Law.
D 1 am exempt under Sec. . B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby Anna under penalty of perjury one of tha following declarations:
1 have and will maintain a Cenifieare of Consent o self-insure for Worker's Compen-
sation, u provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is is =&
D 1 have and will maintain Workers Compensation Insurance, AS required by Section
37M oldie labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. ' 1 7.(h)) Policy No.: (I S S O I
E CTC 1 KIE�PTION FROM WORKERS'
COMPENSATION INSURANCE
.
( bisection need not he completed irtle fcoak is fmonc hundred dollars (SIM)
or less.)
I anify that in the perionaaace of tM work for which this Permit is issued, I shall nut
employ any person in any manner an as to become subject in tM Workers Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: if, after making this Certifiesm of Exemption, you should
become subject in the Worker's Compensation previsions of the LaMrc Cade, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
( '
I hereby affirm that them is a construction lending agcney for the performance of
the work for which this permit is issued (Sec. 3097, Civ, C.)
Undoes N.
'
l.crulm'a Add.
I anify that 1 have read this application an sate that the above information U
correct. 1 agree to comply with all city and county ordinances and fate laws relating w
and hereby authoria rtpmsenutivss of Nis City to enter upon the
Wilding cetioned
.
alwvrmemidgry property for inspection purposes.
(We) Agra to save, indemnify and keep harmless the City of Cupertino against
nobilities. judgmentsecosts and expevea which may in any way accrue against acid City
Aconsequence LICAN or the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: OL)•
Date
SOURCE�R gULATIONS.
VLI�-`^Y,• 7/1 1 200
Re -roofs
Signature Of Appliam/COntractor Date -
HAZARDOUSMATERIALSDISCLOSURE
Type of Roof
Will the applicant or future building occup rat store or handle Mallous material
az &rind by the Cupeninn Municipal Code, Chapter 9.13, and the Health and safety
we. section 15531(a)7
D Yas VNu
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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 car rmnre eaaain sae ,nt nx a
PP g P equipment or devices which
t r g
it hazardous air conammana u defined by the Bay Area Air Quality Management
all new materials for inspection.
istria7 f
Dyes V.
I have sad the h..Nms materials mquimmenuunxr Chapmr6.95 of the Califor-
nia Health & Sycty Cox, Securer BX)5, 8533 and25534, I unxrsund thuiftM building
does not currently have a tenant, that it is my responsihility m notify the occupant cruse
re Inch must xmIpriorwiesuanaoraCadrm !Vup7�
Signature of Applicant Date
Y - /
All roof coverings to be Class "B" or better
Owner or authorized agent Date
e
NOW
S&
CITY OF
CUPERTINO
CITY OF CUPERTINO c�
REPIPE /SEWERSIMAIN SERVICE
PERMIT APPLICATION FORM
APN# j2 �7 rJ d 7C
PPERMTIFEE
Plumbing Permit Issuance
Date:�Jt�"r 14F2cro �i
Building Address: 105� Pl A Lht W E5
�t2
Re i e of Fixtures
Owner's Name:
>71 --7.r t, A r,A 7-,A i,�2 o v.!
Phone #: Cam( F's
Bldg. Permit Fees
BUILDING
-7 3 2 6q 6 7
Contractor: Phone:
(4 o'8 >
License #:
17IZA,t
27801.70
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Contact: Phone:
(�L� 1
Cupertino Business License #:
`f3+Pnt U
PLUMBING
l' O 7+15
Building Permit Info:
BUILDING
Bldg ❑ Elect ❑
Plumb 9
Job Description:
�t STa� 'T U STt`� dv-iJ
` 3U
645:r�('!
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID
Fee 1)PSrrintinn
W� 3 a 2,0 l
A q�. 7 7
PPERMTIFEE
Plumbing 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
W� 3 a 2,0 l
A q�. 7 7