04070021 ` r
CITY OF CUPERTINO < 1's„»,Ir
BUILDING DIVISION PERMIT %CONTRACTOR INFORMATION :
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BUILDINGADDRESS: BAY AREA REPIPES PERMIT ND04070021
20130 APPLE
OWNER'S NAME: PERMIT ISSUE DATE
dh JASON & MARY TAM 1
ONE: SANITARY NO. CONTROL NO.
(408) 371-5763
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y00 LICENSED GDNTRACIDR'$DECLARATION O O O O
on
e
-.5 I Mn 70 affirm that I am licensed under provisions of Chapter 9mylicc=s l� ell
S Z a, with Sc1 him, y affordof that I o Been edBusinessder pr visiossiof Coda a9(commencing
cen is tfBass 1k1 [I�t
j�? Lfml O,ree andeif 3(p REPIPE/WATER ER
Ltecne Clas - Lk.M
Z pFpq Dem Contacmr rr.0
ARCHITECTS Sia< 1 understand my plans shelf used a publiRAO
p1 records
IIIA 2004
�yU
3 a0 t, Licensed Professional
OWNER-BUILDER DECLARATION t-'7 p p fr ®�
iy 1 hereby affirm Nal 1 R-exempt from the DECLARATION
License Law for the iL!®1 aD�''J'1 ell{III�
p 0 following mason.(Section 70111.5,Business and Prefectures Cade:Any city or county
yS ff which resume a Permit to eonsuum.alar,improve,demolish,or repair ny stmmure
prior in its issuance,also requires the applicant for such Permit to Glc a signed au-mens
FiGthat he is licensed pursuant to the provisions of on,Conuxwr'sUmnuLaw(Chapter 9 Sq. Ft. Floor Area Valuation
¢� (commencing with Section 7")of Division of the Business and Professions Cole)or
i $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of �r�.,i��am
Section 7031.5 by airy applicant for a permit subjects the applicnt m a civil penalty of Na-4ni l are)0 OccupancyT e
not more then five hundred dollars(SSW). yP
❑1.as owner of the property or my employees with wages as their sole compensation,
will do she work.and the swcture is not intended or offered for sale(Sec.7044,Business
and Professions Cade:The Conumcmrs License Law doe:not apply m an owner of Required Inspections
property who builds or imp tem flescon,and who doessuchworkhimelfor through his
own employees,Provided thatsuch improvemnts au not intended croffemd forsake.IL
however,the building or improvement is mid within ane year of completion,the owner.
Wilder will have the burden of proving that M did nen build or improve for purpose of
sale.).
❑1,as owner of the liniment,am exclusively contracting with licensed contractors to
convect the pmject(Sec.7044.Business and Professions Code:)The Contractors Li.
cone law does not apply 0 an owner of property who builds or improves domon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Convaclors
License Law.
El 1 am exempt under Sec. ,B k P C for this ration
Owner Date _
WORKER'S COMPENSATION DECLARATION
1 hereby affirm undo sandy of perjury one of ox fallowing declarations:
I have and will maintain a Certifies-of Conum muff-insure for Workers Comped.
cation,as provided for by Section 3700 of the labor Code,for the Performance of the
work for which Nis permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Semon
3]OO of the Libor Conic,for the Performance of the work forwhich Nis pmm;I is issued.
My Wmkci's Cqp11 ro-�perr.non l)surance carrier and Policy number am:VAA1 T
Cartier.11A�A rel Policy No.:je7.%7 24871
CERDFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Dissection treed nor M completed Ron .it is for mo hundred dollars(S 100)
or lea.)
1 cenify that in the performnec of the work for which this it is issued,l shall not
employ any person in any ma�rAO`az I, mesybidct tntK Wo rkcrs'Cianxuation
Laws of California.Da-APPRI / ,V y♦�// ,,11�7
Laws
nt
NOTICE TO APPLICANT:IL after making is cm mane of Exemption,you should
become subject b the Worker's Compensation provisions of the Labor CMe,you must
.J O forthwith comply with such provisions or this permit shall be dimmed mwtkcd.
Z ren CONSTRUCTION LENDING AGENCY
f" I hereby affirm that there its communion lending agency for the performance of
fY, the work(or which thus permit is issued(Sec.309'1,Ci,C.)
W Lcolcrs Name
z Lenders Address
J O 1 certify don I have read this application and into Ne the above information is
ly F
correct.I agree to comply with all city and county eminences and sero laws reining in
D V building convection,and hereby authorize representative of this city to comr upon the
e"""'a'miuned property for inspection parpowine,sec
F y (We)agree to save,inti" mfy and keep harmless the City of Catena.against
fn liabilities.]mr.or. the costs and o..lR whichmryin any way accrue against said City
V z 'A"L'qucnceI the granting to..
A permit.
'-" APPLICANT UND AND WILL COMPLY WITH A N -POINT Issued by: Date
SOUR O
D Re-roofs
Signnurt fApplicanUConlncmr Da-
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding oceupam stone or handle hi ardous material
as defined by the Cupertino Municipal Code,Chapter 9.Pi,and 0o Health and Safety
We.Section 155J2(a)? All roofs shall be inspected prior to any roofing material being installed.
❑res
Will the appficem nr fw m bullong occupant use cquipmcor or deices which If a roof is installed w' ut first obtaining an inspection,I agree to remove
mit hazardous air contaminants se defined by the Bay Arca Air Quality Management all new materials for ns ection.
District?
Yes
[he,.on'the hxa oats rials rcyuiremcnts under Chaperh.95af the Califon
nia Hcel"s tyc 505.25533nd]5534.Iundcrs Mifd,c Wilding / d
does.not c a- lis my respmuihility m netify dm up t of the 4 t
reyarem moss et brew uanceofaCcnif-ama� ynco y Sig a[ureofApplican[ Dale
Owner tar oriucd agent (e Dam / All roof coverings to be Class 'B"or better
Community Development
t f 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�PERTINO
Building Department y
JOB ADDRESS: PF IT #
0407bO
OWNER'S NAME• ph M rr(y j PHOM # (�$-- /p( fC.
GENERAL CONTFACTOR: n FAX'#/
I am not using any subcontractors: /�__
Signature / Date
Please check applicable subcontractors and complete the following information:
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 h �v tS Z 3 7-7 3
Roofing
Septic Tank r
Sheet Metal
Sheet Rock
Tile /l
�—a n /Contractor Signature Date
CITY OF CUPERTINO /
�'. REPIPE/SEWERS/MAIN SERVICE
• CUPEf�TINO PERMIT APPLICATION FORM
APN# / S3
NPhon-e*
Building Address: I O n /e /r{
Q t ,
Owner's Name: �j� //d/ r6 S
Contract /Kl�i pt Phor�� // 3 License #:
Cont Phone: Cupertino Business License #:
Jw`z✓t<or'1
Building Permit Info: 37
Bldg ❑ Elect ❑ Plumb
Job Description: < I
( :06 ett4 r{ 11o✓,5C w � �''tR-•h �M'4T'✓ 69-�fr'
Resitial ercial ❑
ostofProjec
Qty. if
A ale Fee ID Fee Description Fee Group
BP F Bldg. Permit Fees BUILDING
PPERM FEE Plumbin Permit Issuance PLUMBING
BPREP E Re i e of Fixtures PLUMBING
BPFDCTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License I BUILDING
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