04090226 CITY OF CUPERTINO "
BUILDING DIVISION PERMIT WONTRACJTOR INFORMATION ,
- 3, w- „: -..:,•"nom. �>hx::-.wvv'§?F. a. % a,.
BUILDINGADDRESS: SHEPHERD SERVICES PLUMBIN "r NO04090226
23 7
'OWNER'S NAME: PERMIT ISSUE DATE
SCOTT MURRAY
ONE: SANITARY NO. CONTROL NO.
4085597160
ARCHITECIENGINEER: BUILDING PERMITINFO
BLDG EI"LT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACTOR'S DECLARATION — - — ---— —
Yu+FF I bemby affirm Nn I Am licensed under gqm� viion$of Chapter 9(comm...I.& Job u 0
`Z. with SccuAp7000)sfDi,isiM3.Um BusinessWsd ProfPssiom Cade.W littnseis
Cay
in T. rec ^G_ �g 1 GAS LINE TO BBQ @ BAC
J y�? Llccsuoc
�'❑ Dam •� c Canusno
MON
I undadmad my plans sshall and u pp ubl�ic=w& t)1Cfp
JyU
SEP 22 2004
C y
Licensed Pmfcssional
OWNER-BUILDER.,IAm. DECLARATION BUIL®�N
I later,aRnm Nat I am exempt from the Cantraeora License Iaw for the 9DJ L
i
20 following reason.(Section 7031.3,Business and Professions Code:Any city m county
which requires A permit to enmuuct,almr,improve.demolish,or repair any MorM.
prior an its ism soca.AlM requires the applicant for such permit m file a signed statement
that he is licensed pursuant to the provisions ofthe,Contractor's License Law(Chapmr9 Sq.Ft. Floor Area Valuation
C (commencing with Section 7")of Division 3 of the Business and Prohossions Carla)or
_ that W is exempt therefrom and the bud for the alleged exemption.My violation of
Section 7031.5 by any applicant for.permit subjects the applicant to a civil reality of 34&Ndtuhbcr00 Occupancy Type
not mom then 0m hundred dollars(5500).
❑I.nm ofuispmpmn ormyemploynswiNwg mheiruleeompenudon,
will do thcwork.and theawaure is not intended m.(fared forxala(Sec.7044,Business
Add Prolamin.Codhe e:TCanaeors License sow does rat apply to An awar of Required Inspections
property who Wildsmimpmvu rhmmm,Mdwha doesauch work himalfor through his
own employees,provided d usuch improvements Me not intended or offered for sale.IL
however,the Wilding or improvement is sold within one yeti of completion,the owner.
builder will have the Widen of proving that be did not build or improve for Impose of
cele.).
❑1.as made,of tW property.am exclusively contracting with licensed contractors to
construct the pmjem(Sec.7044.Business and Profusions Code:)The Contractor's U
seem Law docs not apply As an owner of progeny who Wilds or improves themn,ntl
who contracts for such pmjects with a eontractads)licensed pursuant to the Contractors
License Law.
❑I Am exempt under Sec. ,B&P C for this rearm
Owner Dam
WORKERS COMPENSATION DECLARATION
1 bemby affirm under penaby of perjury mm of the following declarations:
1 ban and will maintain a Certificate ofCoamm to self-insure for Workers Compen.
sauon,As provided for by Section 37M of the LMor Code,for the Wofordt of the
work for which this permit is issued.
ve
1 haand will maintain Worku Worker's Compensation Insurance, required by Section
37W of NC ISWr Code,for the performnee ofthe work forwhich this permit is issued. '
My Workers Compensation
Insurance carrier and Po' number
am:
ERTIFlC F EMPnON FROM WORKERS'
///
COMPENSATION INSURANCE
mais renin need an[k completed ifthe Permit is forone hundred dollars($100) .
or lea.)
1 unify that in the performance of the work for which this permit is issucd,l shall not
employ any person in any manner so as to become subject m the Workers''Compensation
Laws of California Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Work.',Compensation provisions of dm Leber Code,you mud
.,O forthwith comply wit such proviaiom m this permit shall W deemed revnked.
Z( CONMUC71ON LENDING AGENCY
I•+ I betcby affirm des then isPerformanceconstruction lending agency for the Performaof
7av� the warts for which this pumit is issued(See.3097,Co.C.)
Ld Q Lender's Name
0.Z)Z Us&,.Md.
U Q 1 certify that 1 have mad this application sad Auto Nat the about information is
F-• entree.I agree to comply with all city rad county ordinances and sale laws relating to
p V building commeion.and hereby ambouae mpreuntauvs of this city to enter upon ft
ahovc-mcnuoncd pmpc costs
for Md a pe expenses
purposes.
F y (We)agree u ase.indemnify and kap harmless the City of Cupertino against
fA liebiliues,judgments.costs ndczpcnus whicM1 may in ray wyeccroc against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR R Li�NS�k,,,�O I rt
Signature ofd pli V dnuu' ser — "��'C�.)/•V Dina Re-roofs
AZARDOUS MATERIALS DISCLOSS RType of Roof
Will the applicant W form building occupant stow or handle hazaNam material
u defined by the Cupertino Municipal Code,Chapter 9.12,and do,Health and Safety
we,Sc y.zss32(a7 All roofs shall be inspected prior to an roofing material being❑Yes Na p p y g g installed.
Will the applicant or future building acupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.mit hazardous it car.,.ans3yda0ncd by the Bay Area Air Quality Management all new materials for inspection.
DiWitO
[I Yes E]No
I have mal the huardon materialsrequirements under Chapter 6.95 of the Califor-
nia Health&SafctyCode,Sections 25505,25533 rad 25534.1 undcrsmnd that done building
m A
does not currently Want,that it u my responsno
ihility W tify due occupant or on,
re men.. It k I,t±itowissnnc.ar.cemra�.ar��j Signature of Applicant Date
a hod agent I — I Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
1 ' fit' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PEBMI#
,Z-3 60u� (�)l (-)L 0Q k-
OWNER'S NAME: G c 4- L r�ol PHONE Ste-71
GENERAL CONTRACTOR FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation
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
i
61A /Contractor Signature ate
CITY OF CUPERTINO 6
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 z)C-
Building Address: lJ
30
Owner's Name: Phone#:
IVt
Contract r: \ hone: cense#:
5 o9I3
`C)ont�: Ph ne: Cupertino Business License #:
�-� _ 4Z
Building ercmt Info:
Bld X7 Elect ❑ Plum
Job Description:
Q it �l Gr r
Residential Commercial ❑
Cost of Project: J�
Qty. if
A Tcable Fee ID Fee Description Fee Group
PPERMTTFEE —plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BU LW1 Business License BUILDIN