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04040028ym2 pp �R ZiZ ,m,�p U o0r �00 y'N F�< asFO i5$ CITY OF CUPERTINO "`= BUILDING DIVISION PERMIT Vt-ONTRACTTOR_INFORMATION BUILDING ADDRESS: PERMIT "04040028 2 OWNEWSNAME: PERMIT ISSUE DATE KEITH BARANOW NE: SANITARY NO. CONTROL NO. ARCHIMC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Chapter 9 Job Description p I bertby affirm that I am Ilcemd under provisions of (commencing with section 7")of Division iof ted BasiPmfcssions Code itliceveis in full force ,-�" Lkenu 1 Lic. g REPIPE (HOT & COLD WATER LIN nn Data corn tor .a"' —CONTRACTOR: MASTER PLUMBING�tl�41��® ARCHITECT'S DE(21LAWON l undo y plans shed he and as palmi a menrds MAY 24C2004 Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am axempt from the Contractor's Lima. Law for the ��®�� following mason. (Section 7031.5, Business and Professions Cale: Any city or county U which requires a Permit to constmcs. alter, improve, demollah. m repair any struclum prior it, its istnan[e..t. mcird e{ tlm appheant fms.ch permit to flea signed amlemem dust he is licensed pmsa6nt to the pmvismm ofduc Contractors Lee. Lia, (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 0000) of Division J or the Businessand Professions Code) or Y'� Nu he is eaampt therefrom and Ne bssu for the alleged exemption. My violation of APN Number OccU anC T p y y� Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than Bae hundred dollars (S500). 32613095.00 ❑T,asownerofinepmpMy,ormyemployaawileweedutheirmlecompemdon, will do thewon; and Ile he Cron Is errs Lic ed ofowrtd s Out apply 1061, Buinw and Profession; code: The Contrutors Liam law docs Out if an owner Required Inspections proown erty his is dousoctende oroffrordumugh mploy ,provided that suchimprandwho own employers, provided that such improvements art not intended ora@red e Ir, the owner - n Ne building orwproveroviingdust widuinone year of completion. Neeof Wilder will have the burden of proving teal be did not build or improm for puryuse of sale.). ❑ 1, as coots, of the property am exclusively contracting with licensed camtraemrs m construct the project (Sec. 1064, Business and Profmions Cede:) The Contractor's Li. ' am Law docs ret apply m a^ owner of property who wilds or improver themon. and who contracts for such projects with a contrscmKs) licensed pursuant to the Comtrutor's Lkem Law. ❑ I am emmpt under Sec. . B & P C for this ..on Owner Des WORKERS COMPENSATION DECLARATION 1 hereby affnm under peulty of perjury, one of the following declarations: 1 have and will maintain a Certificate of Consent to self -insure for WorkelsCompm- usion. u provided for by Section 3100 of the Labor Code, for the pmfmarnme of the work Tor which this permit is issued. 1 have and will maintain Workens Worker's Compensation Insurance, u mgvited by Section of the Labor Cade. for the Per.. of dm work per which this permit is issad. My Worker's Compensation Insurance carrier and Policy numab��er Cartier. S'r�I %r Fr/NLs Policy No.: EC RTIFICATE OF EKEMMON FROM WORKERS' COMPENSATION INSURANCE Tlhuuctiu need not kcmmplemd ifure permit is fm one hundred dollars (SIM) or less.) I certify that in use Performance of the work for which this permit is issued, I shall not employ any person in any manner so as in become subject to she Workcoc Compcuxdon Laws of California. Dam Applicant NOTICE TO APPLICANT: If. after making this Cenificam of Exemption, you should became subject m the Worker's Compensation provisions of the Lads Code, you mine fmMwith comply with such provisions or this permit shall be deemed mucked. CONSTRUCTION LENDING AGENCY I bemby affirm that frt it. amtmctinn lending ageay for ted performena of the work for which this permit is issued (Sec. 3091, Ci, C.) Isndct's Name Lenders Address 1 ttnrry Nal 1 have mad this application and sus Nal the above information is conmL I agree to comply with all city and county onlirsnces and state lawn misting in Wilding construction, and hereby mmoriae representatives of this city to enter upon Ne awm-m6nuoned Pmpcny for inspection pugwsea (We) agree to uvc. indemnify and keep harmless the City of Cupertioo against mcnts.cmmand experucaw' may rn any way accnm agvut svd Cily liabiliuu.ju'CL- in con cc Ne gran mil of this pc Sj?P ICA�UNDERSf S AN WILL COMPLY WITH ALL NO I Issued by:%Dat RRUU - Re -roofs ig pplicumV on a e HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or lot= Wilding occupant some arhandk hauNom material as defined by the CuMninouII n Code. Chapter 9.13, and the Health and Safety ode, Sccuon 25533(.)7 ��^'y/�� ❑ Ye All roofs shall be inspected prior to any roofing material being installed. Will me apphcaul o, future wilding caupant sex equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove air eonmmink fined by she Bay Ara Air Quality Management all new materials for inspection. District?arardnu ❑Yes No I he. remlth trete materials requirements under Chap¢, 6.9Sof Gli nice Health&S Nou 2SXI5.35 JanJ 35536.1 undcrsundthat, dui rung Jona not c rad a tenon as i Y rtspouiM1ility m notify the d o f the ` U m,.im ts. m P aof.cen Lnuoll O—rSigrrature 6ffp6licant Difte All roof coverings to be Class "B" or better owner ,tithe .cl.,,.I Dam tl 400i �UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department ,7jQ,Bz 35r 6/L RMIT # C)on OWNER'S NAME : , ee' Owl NONE # p—(, — p GENERAL CONTRACTOR: Electrical FAX # Excavation I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: dri7r/ Contractor Signature 4a4t—e 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 c& ted. Roofing Septic Tank Sheet Metal Sheet Rock dri7r/ Contractor Signature 4a4t—e t IWITYOF CUPERTINO CITY OF CUPERTINO o u o ZS" REPIPE/SEWERS/MAIN SERVICE PERMIT APPLICATION FORM r APN # 76 -Plumbing Permit Issuance PLUMBING Date: Re i e of Fixtures PLUMBING BPERMFEE yea Building Address: Z 7,36-3 BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service Owner's Name: f / BPSEWER Sewers Phone #: l/ Ih 0 PLUMBING BUSLIC Contractor: Phone: License #: nG�0-G - On ®I Z 3Z C act: Phone: Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Job Description: #-112'bZd rt TP �i Residential CTmercial ❑ Cost of Projt y: if nDlicaLle FeeM rn.n .; 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 Dis osal PLUMBING BUSLIC Business License BUILDING