03080056 d CITY OF CUPERTINO "
BUILDING DIVISION PIRMIT CONTRACTORINF,O$MATION•
BUILDING ADDRESS: MIKE COUNCIL PLUMBING INC PERMIT 50.03080056
10865 BARRANCA DR
OWNER'S NAME: 1977 OITOOL AVE PERMr ISSUEDATE
CASLER HARRY G AND ETHEL J 08/13/2003
NE: (408) 272-4900 SANITARY NO. CONTROL NO.
ARCHITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 = 0
X0ZLICENSED CONTRACTOR'S DECLARATION IOh DDSCrIpIIOn
U 1 hereby affirm that I am littn.d under provisions of Chapter 9(ccmmcneing
I with Section 7000)of Division 7 of NC Business and Professions Code.and my license is
g z �if.11 nsondeffect- Ln7�loZto� MAIN WATER SERVICE
_ �o Lm.
ig Date om..cn A d fou/tI
e££ A CHITECI S DECLARATION -yam _
CC l understand my plans ahnll he ured.puldio records a�fgh��'% AUG 2 0 2003 y6 / 1
G Liccnud Professional
ss OWNER-BUILDER DECLARATION
I I hereby a(frm that 1 am exempt from On,Contramors License Law for the BUILDING DIN
5 B fallowing mason.(Section 703 1.5,Business and Professions Code:Any city or county L g V l71
which requires a permit to construct,alter,improve,demolish,or repair any Structure
82600
-xi prior to its issuance.Alco requites the applicant for uch Permit o file a signed Statement
_ < that he islittvedpursuant tolbeProvisions Ofthe Comracwr'sLicense aw(Chapter 9 Sq.Ft.Floor Area Valuation
�ct
(commencing with Section Division 3 of the Business and Professions Code
s g of 32601012 . 00
Net he Is exempt therefrom and the basis for the allcgcd cumpllon.Any violation of
Section 7031.5 by any applicant for a permit subjects due applicant toacivil penwyof APN Number Occupancy Type
not more than five hundred dollars(3500).
D I,m owner of the propeny.or my employees with wages As their core compensation.
will do Ne work.and the structure is not intended or offered for sale(Sec.7044,Business 10 6 —
and Professions Code:The Contractor's License law does not apply to an owner of 202 — UNDER 8 11V G
property who builds or improves thereon,and who does such work himself or through his
own employers,provided that such improvements are not intended or offend for Ask.If, 301 — ROUGH PLUMBING
however,the building or improvement is sold within one year of completion.Ne swum.
builder will have the human of proving that M did not build or improve for puryose of 302 — TUB & OR SHOWER
'ale) 502 — FINAL PLUMBING ENERGY
D 1,as owner of the property,am exclusively contracting with licensed commitments to 506 — GAS TEST
construct lie prefect(Sec.7810,Business and Professions Code:)The Contractors Li.
cense Law does not apply or an owner of progeny who builds or)mproves Neeson,and 507 — FINAL PLUMBING
who contracts for such projects with a contramor(s)licensed pursuant to the Commerce.
License La-
0 I Am exempt under See. .B A,P C for this..on
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declare iota:
I have and will maintain a Certificate of Consent to self-insure for WorkersCompen-
1037.1W'
on,an provided for by Section]700 of the Labor Code.for the performance of the
rk for which this permit is issued.
1 lave and will maintain Worker.Compensation Insurance,as required by Sued..
of Ne Ichor Code,for the performance of the work for which this permit is issued.
Work/cr�a/C�nmpensal1ion huurnnce carticr v:y numher art9,(7�BirQ! I�GVII�V1 yNo.:Zoua��u�/-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CrIds Auction need not be completed if the permit I.rnrme hundred dollars(SIM)
lea.)
I certify that in the performance or Ne work for which this permit is issued.I shall not
employ any person in any manner an as m become subject o the workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this Cenificau of Exemption,you should
become subject m the Workers Compensation provisions of the Labor Code,you most
.,,Z forthwith comply with such provisions or this Permit Merl the deemed mowed.
u O CONSTRUCTION LENDING AGENCY
[-. I hereby affirm that there its construction lending agency ler the performance of
fl,rte. the work for which this gemtil is issued(Sec.3097.Civ.C.)
W Lender's Name
6. Lendeis Address
U I ramify that I have read this application and nate that dm above information is
Ie. F comm.1 agree to comply with all city and county ordinances and sum laws relating to
p U building construction.and hereby interim mpresenutiw or this city to enter upon the
Move-mentioned property for inspection purposes.
(Wc)agree la veva,indemnify and keep harmless the City of Cupertino against
.H.iy riebilidrs,judgmen¢costa and expenses which may in any way Accmc against said City 411
U Z in crosegllevae,of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOURCE REGUL TIONS.
Re-roofs
S' oo
f App am/Conlracmr Dam
HAZARDOUS MATER LS DISCLOSURE Type of Roof
Will pplicant or future building Occupant store or handle haruduus material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ods.Section 25532(.)? —/ All roofs shall be inspected prior to any roofing material being installed.
DYa Lyra
Will the applicant Or future building Occupant usc equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haxamnua air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
' iloicl? /
DYcs mM6
1 have road the hasardous materials requirements under Chapter 6.95 of rhe Califon
.is Health A SofclyCode,Sailors 25515.25533 and 25534.1 mccmwd thea if the building
does not currently hoc a Imam,Nn it 4 my rasmoibirity us notify IM occupant of the
nshomumwnmhmy nor put issuatmeonCmuflcate fkcu n ignatureofApplicant Date
er
ownn uthorized agent Date All roof coverings to be Class"B" or better
CITY OF CUPERTINO
' REPIPE/SEWERS/MAIN SERVICE 3
IT
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 / D o/ Date:Q_I _ 0-3
Building Address, S CJ
Owner's Namev 1 1 Phone#:
Contractor: p pI � Phone: 40b v License
i V1 U
Contact: o e: Cupertino Business License#:
`� Al mo U; 83(, - /sx-I
B ' 1 t Info: /
Bld Elect El Plumb E
ob es ption:
Men�vi w er 5erv'ce.
Residential Commercial ❑
Cost of Project:
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A c 1 Fee ID Fee Description Fee Group
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
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