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CITY OF CUPERTINO
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DIVISION PERMIT
ONTRACTbRINF,ORMA.TIONN
BUILDING
BUILDING ADDRESS:
I RTTTrH PT
CUPERTINO PLUMBING
PERMIT NO 04030134
-1-1`11R2
OWNER'S NAME:
PERMTC ISSUE DATE
ONE:
SANITARY O. SNOL NO.
ARCHITECTMNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
1 bcmby affirm that l am licensed under pmvisons of Chapter 9 (commencing
P
with Section 7") of Division Sof W Busivas and Pmfessiou Cocteand mylicense is
in full fume and c@ct ,%
umn.0 s tia3� ue.x q=
REPIPE/WATER HEATER/WATER SERVICE
Date - y'
CTSD CL
DECLARATION
As
shall used
1 understand my plans shell he used a public mcoras
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Conuactar's License Law for the
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following mount. (Section 7031.5, Basines and Professions Code: Any city or county
which tequti s a parasitic eonuuct, alar, improve, di mulkah, or repair any structure
prior no its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the Provisions°fthc Contractor's Limn. faw(Chapur9
Sq. Ft. Floor Area
Valuat on
(commencing with Secaon7000) of Division 3 of the Busineuaad Professions Cast) of
that he is exempt therefrom and W bus for W alleged exemption. Any violation of
3 YMhftdgro 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
act mart than five bundred dolln
0 I, as, owner of the Property, or my employee with wages u their sok compmadmi,
Required Inspections
will do the wank and the structure is not intended proffered for sale (Se. 9041, Business
and Professions Code: The Connector's License Law does rot apply In an owner of
pmpeny who Wildsoimprenes thereon, and whod°essuch work humselfrr Waugh his
own employ=. provided that such improvements are not intended or offered for ale. If.
however. Use building or improvement is sold within one year of completion. the owner-
F' RALE®
builder will have the burden Of proving dist ho did not build m improve for Purpose of
.Jr.)
0 1, as owner of the propert, am uOiOsiwly eonlncting with licensed conVa[mrs In
APR
construct the project (See Proletariat7044, Business and ProlesCode, The Conuvaota Li-
L uoY
cense law dors not apply to an owner of propeny who builds or improve thereon, and .
who concocts for such pmjeeu with a c°m s coKU licensed pursuant to W Caricatures
Lleervn law .
BUILDING
lam exempt undo See .B&PCfrr Nu rtuon
Owner Data
-
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one Of the following declarations:
I have and will maintain a Certificate of Consent to of -insure for Worker's Compen.
amm, u provided far by Section 3700 of W Lilian Code, far sine pethotmance Of the
work for which this perms is issued.
I have and will maintain Worker's Compensation Insurance, u.quired by Section
37 fthe Tatar Code, fro the perfnmanee ofthe wish for which this Permit is issued.
My Worker's oro cranio ryvuranec anicrand P°lirynumberam: ��,C
Cartier:-19fPolity No.: bot) y
CER'FIRUAIE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
OTiu section need trot 4compkud if Ih permit is for one hundred dollars ($ 100)
or less)
I unify that in the performance of the work for which this Permit is issued, I shall not
employ any fiction in any manner so u to become subject to the Workers' Compensation
Laws of California. Data
'
Applicant
NOTICE TO APPUCANT: If. after making this Cenifimu of Exemption, you shauld
become subject m the WOrkV a COmperation Provisions of dM LabM Code, you mLLL
faMwith comply with such provisions or this Permit shall M deemed mvnked.
CONSTRUCTION LENDING AGENCY
I hereby alErm that there its construction lending agency for the Performance of
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thr work fur which this permit is issued (Sec. 3099, Civ. C.)
Lender's Name
Isnder's Address
I cenify that I have mad this application and state that the above information is
-
coma I agree in comply with ajl dry and county ordinances an Stata laws misting to
building conswction,andhe yauthanno Pep utivesof schyseenteruponthc
ahovc-mcuiomca p ny f impecapn pe s.
(We) ego maamnVy and tr burnim City of Cupertino against
liabilitiu,judg WLc andexpcn is ch may in way aeemcagaiut said City
in thennfngyyJJ11
Wspe n./
PLICA rte of it.
APURCE UN RS D5� LL LY ALL NON -POINT
Issued by: 2�(
SOURCE U ii _— '
Date
Re -roofs
I' o mr / Date
HAZARDOUS I(IS uBE
Type of Roof
u
ill ppplinnwrfumm buil' ml no¢OrM�k hanrdaus material
d by c Cupertino cipat spar 9.1]. an the Hcal0 dna Safety
ction 23532(x)?All
Yon oill
roofs shall be inspected prior to any roofing material being installed.
(oda.
the applicant or future building account use equipment Or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
rdou air commnanu u defined by the Ba Area Ail Quality Management
all new materials for inspection.
Yce
ave zIW and aria aqui nuunderCMpter6.95 orIM Calif°r.
nice Hulth& cry Se IS 534. l undersand thatifthe Wilding
docs note nil a �ic t' my ibiliy m notify the emupul of One
mgnmm ts n mmmeterr
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owne t u o seat / Daa
s
rc
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
PERMIT #
OWNER'S NAME:
PHONE # 257 9
GENERAL CONTRACTOR:('/ ✓ li-tpurrl /
FAX # �j�j OLo I o
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
L&ALAV
er/Contracto i a e
L61(9.
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
1>6
Plumbing
Roofing
Septic Tank
Sheet Metal /I
Sheet Ro
Til
L&ALAV
er/Contracto i a e
L61(9.
Date
0
0
•
a
CRY OF
CUPERTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE ° 3 c,/
PERMIT APPLICATION FORM
APN # I l.P C;)- !
oc;, (.(%
PLUMBING
Date:
I
Re i e of Fixtures
Building Address:
BPERMFEE
Bldg. Permit Fees
Owner's Name:
BPFIXTURE
Pblg. Fixture
y,)�J: P5r G
Contractor:Phoned
' P/' f'1U
�
4 Z612-6L01
6� Ci^,9 /
7 L
License #��q e7 0S—
Contact:
Phone:
BPSEWAGE
Cup ino B siness License #:
Building Permit Info:
Bldg ❑ Elect ❑
BUSLIC I
Plumb Ek
BUILDING
Job Description:
'
v
Residential Co
erc al ❑
Cost of Project:
(tel C.J f
Qty. if
Applicable Fee ID
Fee Descrintion
FPP (:m m
PPERMITFEE
Plumbino Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pblg. Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC I
Business License
BUILDING
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