04080052CITY OF CUPERTINOs"^-='�
BUILDING DIVISION PERMIT
�°CONTRACTOR INFORMATION
BUILDING ADDRESS:
""""04
ERMIT NOO 4 0 8 0 0 5 2
OW NER'S NAME:
PERMIT MUE DATE
ONE:
SANITARY O. ONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
OCSCTIP
Ib Description
s of Chapter 9 (commencing
at I am licensed dprovisions rovision
1 hereby affirm Nun
with Section 7Orl of Dlvlslan 3 of Ne Business and Pintas m Code. and my ileac is
in full force and effect.
License Class Lie.I
REPIPE (2.5 BATHRMS/KITCHEN &
Dam contractor
NEW PLUMBING FIXTURES)
ARCHITECTS DECLARATION
1 understand my plans shall he used As public records
Licensed Pmfcsvional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contmcmrs License Law for the
following reason. (Section 7031.5, Business and Pmfcaaimts Code: Any city or county
which myma uiA pmmit rte ennstmet, ahr. improv, demolish, m repair any slruchum
prior to its issuance, also requites the applicant for such Permit to file a signed statement
Nat he is licensed pursuant 1. he owitums of the Conuactor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuat 500
(commencing with Section 7") M Division 3 of the Busimxsand Professions Code) tar
that he is exempt therefrom and Ne basis for the alleged exemption. Any violation Mf
APN Number
Occupancy Type
P Y YP
Section 7031.5 by any applicant for A permit subjects the applicant to acivil penalty of
em Mort then foo, hundred denary (SSW).
❑ 1, As Manor of Oreproperty. or my employes with wages As their sole compensation.
34232023.00
a
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sce. Bee, Business
and Professions Code: The ConwclnrY License law does .MI apply to an Mane, of
progeny who buildsorimproves thereon. and who doessuch work himaelfortuough his
-
own employees, provided Nat such improvements are not intended m offered for sale. If,
however. the building or improvement is sold within one year of completion. the owner-
builder will haw the burden of proving that he did not build or improve for purpose of
®�
sale
contracting with :) The Contractor's contractors i-
1. a owner of the Sec. 70y am exclusively and Li -
moss Businessandrty wiaui Code:)The
.
La it not(Sec. to an
reuse LawdoesnotApply to Tanaofprogeny who buildsorimproves thcrtrn.and
reon.old
who contracts (m such projects with aconwnor(a) liccrsatl pursuant to the Conmactofa
License Law.
20
O
❑lam exam ndm ,B&PCfor'rt n
y
own 711
74,
WORKER'S COMPENS ON LA ON
Ihertby elfiw under penally of perjuryM of Ne fallowing dalmations:
I hate and will maintain aCeriillWm of Consent to self--Insum for Worket'sCompen-
satirn. as provided for by Section 37M of the labor Code, for the performance of No
work for which this permit is issued.
El have and will maintain Worker's Compensation Insurance, az required by Section
3700 of orebo
lar Code, for the performance of the work for which this permit u issued.
'
My Workers Compemation Insurance arricr And Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
O'hissccd...door Mcconpleted ifthe permit is future hundred dallara nIf ff)
or Icss.)
I ceMfy Nat in one poffmmanee of the work fm which this permit is issued, 1 abet mot
employ any person in any mannerso a to become subject to the Workers' Compersatou
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Workch Compensation provisions of the labor Crile. you must
forthwith comply with such pmvisirnu or this Permit shall h deemed mated.
CONSTRUCTION LENDING AGENCY
I thereby affirm that Nem is a construction lending agency for the Nolurmen a of
the .,it for which this permit is issued (Sec. 307, Civ. C.)
Lender's Name
ILender's Addrees
1 certify that 1 have read this application and sum that the show information is
correct. 1 agree to comply with all city and county oNinanoes and suite laws mining to
.
building conswcrion, and hereby auNorne mpmsenutiwa of this city to enter upon the
a property for las
proris
(We) agree to save, indemnify and keep humless the City of Cupertino against
liabilities. judgments, costs and capenscs which may in any way same against said City
enceetl
consequence
in eonsequenec of Nc granting of this permit.
this Pe mit.
APPLICANT UNDERSTANDS AND WILL CO Y WITH ALL NON -POINT
Issued by: Date
SOURCE UL ONS.
Re -roofs
Type of Roof
S�AAhMKWppIicAoAComAAac,or
HAZARDOUS MATERIALS DISCLOSURE
Will Ih applicant or future building oceupantatore or handle harallous material
Asdcfined by tic Cupen)no Municipal Calc, Chapter 9.12, and the Health and Safety
Code. Semon 25532(a)T �-/ry
❑Yes tl o
All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building occupant use equipment or devieea whim
PP B pan
If a roof is installed without first obtaining an inspection, I agree to remove
it harardwa air conoaminanu as dc0ncd by the Bay Arta Air Quality Management
all new materials for inspection.
isuim7
❑ Ycs gNu
1 have read the hannium materials requirements under Chapter 695 of thc Califon
.is Health&Safety. Code, Seedom255115.25533 and 25534.1understand Naziflhe b doing
does rot eurtenlly haw a tenant. Nat it R my hility m notify the occupant M the
nt
MgaiM t h� Most be me Talus ar,cc,dficamnrle
y�
Signature of Applicant Date
��-It
All roof coverings to be Class ,.B„ or better _
Ow mnad.eaa ant •. -
` J n, Community Development
f J 10300 Torre Avenue
c Cupertino CA 95014
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
�UPEkTINO
Building Departmlpnt
9
JOB ADDRE S:
101a3 m� o U#
ARMIT #
J OS oosR
OWNER'S NAME: -5 S oo-n - -s T
PHONE #.26 -9 -
a., g -GENERAL
GENERAL CONTRACTOR &4om pev 51,Ego l - m IB4,v6
I FAX #
I am not using any subcontractors: o g 6
Signa a Date
Please check applicable subcontractors and complete the followine information:
$� D
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
$� D
Date
0
1�1
CfTY OF
CUPEkTINO
CITY OF CUPERTINO 0- c C),y C) 0
REPIPE/SEWERS/MAIN SERVICE l
PERMIT APPLICATION FORM
APN #
3{a3ao
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Date:
8
Building Address:
BPERMFEE
Bldg. Permit Fees
BUILDING
C -,;?3 /ylA
Pbl . Fixture
T
BPWSVCS
Owner's Name:
PLUMBING
BPSEWER
Sewers
Phone #:
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
�M3 — X00
Contractor:p
Phone:
License #:
iS Z4 m PC—Als
i aln
Contact:
Phone:
X 58 o?Y
Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect
❑
Plumb
Job Description:
RE P /PC
/ �J
o?/ 61�Tll
PG4rp,.g11/4 c11711,e
Residential
Commercial ❑
Cost of P ject:
/P,500.
Qty. if
AnnKahle Fee m
I-- /1.__
PPERMITFEE
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
#2 (-�-? 2
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