05030107 CITY OF CUPERTINO ^
BUILDING DIVISION PERMIT CONTRACTOR+INFORMATION ,
Bu1LDING ADDRESS: CUPERTINO PLUMBING PERMITN'65030107
OWNER'S NAME: PERMIT ISSUE DATE
STEVE BARON jn?C)r7 q T7 ANZA 2117
ONE: SANITARY NR CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
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,1LICENSED CONTRACTOR'S DECLARATION
71F 1 hemby afrirm Nits 1 am li¢vd under provisions of Chapter 9(commencing Job Description
1 Wy with Section TOM)of Divisio7n�3 o�fda Business and Profrssmar Code.and my license is
^ta to<e L License
Cls ane effect. 07 ' Lie.g GoZd90.� REPIPE & WATER SERVICE
j License Clgss
p Data Ca mir -
ITELTS OECLAR TION
Y,Pit.
s s public racorN
is
''v.� c sed Pmfcssional
`D W ER-BUILDER DECLARATION
f / 1 henry affirm Net am exempt rmm the Contractor's License Law for the
_C o fallowing mason.(Section 703 1.5,Business and Professions Code:Any city or county
x m_ which requires a permit to consumes,alter,improve,demolish,or repair any suoaure
'y prior to its issuance.also regldms the applicant for such permit to rile a Signed statement
t?'<
look isueen,edpesuammikepmvixmx.fdmCmCaeto1sl_Clxchw(Chapter9 Sq. Ft. Floor Area Valuation
(commencingwith S Uon7000)of Division3nf Oc Businmand PrafeuionsCmfe)or
that ht thm u exempt ucfroand the thou for the alleged exemption.Any violation of
Schon 7031.5 by any applicant for a permit subjects dm applicant to a civil penalty of 3 6FYPJCaINrgdbCO 0 Occupancy
not mom Nan fist hundred dollars ane(S500). P Y Type
❑1,u awns of Ne propmY.ar mY cmploycu wish wages as drtb sole compcncouon, //�1
will Bothe work,and Nestmcwaunor's License Lw does
apply 7o W.Bulinus gA� pyyy
and eny wh bu Cade:The Conuaceen. rad who law does not apply to an ownerhough is Required In$peCU0115�
own enywhohiprovi id don mthemproven whodocs himulfof though his
ownemployees,provided Nalsuchimprovementsarenot intendedor moffered for role. r.
however,Ncavetngurimprovsmentishat sold he id not year of completion,he ower- /5
builder will have Ole burden of proving that he did not Wild or improve for purpose of T
salt.).
40
I,as owner of the Sec.7property am exclusively Contractingfesss with licensed cnnsracmrs to �C)n�
cerem a d project apply
an a4,Business and property
who Wilds
Cade:)The Conuacme,and.
c law dons not apply to m owner of protons who Wilds or improves thereon,and
when,,La u for such Drojeeu with a eonmctor(s)licensed pursuant to the Convacsob
License law.
I am exempt under Sec. .B&P C for thu reason ry�
Owner Data
WORKER'S COMPENSATION DECLARATION -
1thereby affirm under penalty of perjury one of tht following declamations:
1 haw and will maintain a Cenifium of Consent o self-insum for worker's Compote
7387M
omi ss provided for by Section 3700 of the ISWr Code,for the performance of the
k f r which Nis permit iscooed.
havead will maintain Workers Compensation Insurance,as required by Seeman
of Ne Labor Code,for the performance ofNe work far which Nis permit is issued.
y Worker's Compreruauon Insurance carrier and Policy number amrrier.ri lj �(/i , Policy No.: :'00 Z�
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need notbe completed ifthe Permit is for one hundred dollars(SIM)
or lust)
I Certify Nat in the performance of drc work for which this pvrnis is issued.I shall not
employ any porton in any manner M u w become subject to III Workers Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to Ne Worker's Compensation previsions of Ne labor Code,you must
.JO forthwith comply with such provisions or Nis perm it shat l he deemed revoked.
'Z ti CON STRUC"HON LENDING AGENCY
[-+ I hereby,grim that from is a Construction lending agency or the Performance of
C 7 Nc work for which door permit is issued(Sec.RIO,Civ.C.)
0 tandcfs Namc
Z Len dces Add.
U O 1.miry that I have mud Nis application and sum than the above information I,
Lk. bunco lam ecomply with all city and onfinteraces townrelatingupon the 0 U buildingCimmerian,and herebyyectimt meouts. tivu of this city mcnmr upon Ne S
,r above-mentionedpmpeny for inspection kewsea
(s ju egret re cost,indemnify and keep harmless dm Cis of Cupcnmo ad ity
f N incoitiu'mmice rfiho costs andiloomm,egpmuu whit may in any way attmc against cold City
UZ inconsequuco NDERSTkNofthisPer.
'
^ APPLICANT,UNOERSTANDS A[JEY LL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR EREGU Nv! /\
3_ 70r Re-roofs
I a ppiicanuConuactor Dam
HAZARD TE ISCLOSURE Type of Roof
Will the applicant or fuwre building occupant h
store or handle vardous material
as fined by the Cupenino Municipal Code.Chapmr 9.1 i,and the Health and Safety
c .SWiim2553z(a)7 All roofs shall be inspected prior to an roofing material being installed.
Will the applicant or fuwm Wilding occupant use equipment mar devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haxardnus air coram ommus u defined by the Ray Arta Air Quality Managerrom all new materials for inspection.
DisuicR
C]Yes /, e
IhaveroaJ tiro vardu miebreyy mme4pttsunderChapter6.95oftheCalifuf-
niaHeaWhSafctyLgdc,Scc ns35 d55 snit 5534.Iundersmndout6f Ne Wilding
dont not'limmif ItS� auk- lit is 4cs monthly to nouly Nc oceupant cifthe
mqm o e i =11, so on PC=ofOttpao
ucy) Signature of Applicant Date
/ `�
Dam All roof coverings to be Class "B"or better
m amhorircd t �
Community Development.
10300 Torre Avenue
1It Cupertino CA 95014
Telephone(408)777-3228
CITY 0P Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: . PERMIT #6SQ 3 U I Oq
kms-
OWNER'S NAME: e-- JPHONE #
GENERAL CONTRACTOR: / � FAX # h
I am not using any subcontractors: _
3 '/05
S' Date
Please check applicable subcontracto s 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile i7
(�wner/Co act ignature Date
CITY OF CUPERTINO 3
� REPIPE/SEWERS/MAIN SERVICE OS
CUP `
CITY PERMIT APPLICATION FORM .
APN# -Aa ' 16 - 0,- 1 U Date:
Building Address.-
Owner's
ddress:Owner's Name: Phone#:
mon S�6vv ass X308
Contract r: Phone: License #:
Log 2-5�3 02-LMos-
Contact: I Pfione: Cupertino Business License #:
Building Permit Info:
Bldg ❑ _ Elect ❑- _ Plumb EK
Job Description: ^'
Residential Commercial ❑
Cost of Project:
sc>Jv-
Qty. if _
Applicable 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