03090065 ` CITY OF CUPERTINO Y4 ' N. HFrr .r}43Y5a> 'h. '__O,
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BUILDING DIVI
ONTRACTORINFRMSION PERMIT ATIQgN
a,�dy
BUILDING ADDRESS: PERMIT NO.3 0 9 0 0 6 5
OWNER'S NAME: PERMIT LSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0 0 0
100 LICENSED CONTRACTOR'S DECLARATION
£z0j I herebyeffirm that l am him d dor provisions of Charm )(commcnsurs lob Description
f^=y
wish
hX1. B1ot DivlsionlorN round Pmfcssinnn Coda.aadmylicurals
(s « 5SEWER LINE REPLACEMENT INALM3
CnCONTRACTOR: DRAIN DOCTOR
eeARCNTELT mmR L N SEP
n
I understand my plans shall he rete a
) s PuhIm recnrda - SEP 9 2003
yUk.
�G9
Licensed ProfessionalOWNER-BUILDER DECLARATION
, ^
<f I Malo affirm that I am exempt from she Crsions o License c Law for the BUI�.a�r/'�G
❑O following moron.(Section IIll LS,Business and Professions Cndc:Any city or county , .
� which requires a pamtit m construct,alms,improve,demolish,or repair any structure
-Zi prior to its issuance,also requires the applicant far such permit to rile a signed statement
< thatheislicensedpursuanttofieprovisionsoftheConuxctorsLimaelaw(Chapter9 Sq. Ft. Floor Area Valu4g]000
� C (commencing with Section 7")of Division 3 of the Business and Professions Codc)or
$
that he 0 exempt tecmfrom and the basis for the alleged exemption.Any violation of �,wi v-s.,i.,r.A
Section 7031.5 by any applicant for a permit subjects Use applicant to a civil penalty of � 3 V PaUsti ✓e10 O Occupancy Type.
oat more Nan five hundred delta. S500). "-- "'
I,as owner or the property,or my employees with wages a their sole compensation.
will do Ne work,and she ntmclum is not intended osuffered fouale(Sec.7p .Business Re aired Inspections
and Profession$Code:The Contractors License Law does not apply to an owner of 10 6 - SEWER & ct4ATER p
progeny who builds or improves Nemon,and who doessuch work himself or through his
owncmploymt,provided that such improvements vent intended oraRered for adds.If. 202 - UNDERFLOOR PLUMBING
however,the building or improvement is sold within one ysv of completion,One owner- -
builder will have Ne burden of proving Nat he did not build or Improve for purpose of 301 - ROUGH PLUMBING
Wa.). 507 - FINAL PLUMBING
i a owner of to property.Bad ss and confessions with limbed tome nave i. - - -
came La the project(Sec.9Du,weer of and Fafesproperty
who
Crede:)The vesnherson, std
cense Law corn not apply a an owner of property who sed p or improves thereon.end
who contracts for such projects with a conuaclor(U licensed pursuant m Ne Conu¢lor's
License La-
0 1
aw.❑last eaemq under Sec. ,BkPC far this reaan ,
Owner Date
WORKER'S COMPENSATION DECLARATION . .
1 hereby atflro under Nulty of perjury one of to following dultuatiorm .. _..
I have and will maintain a Certificate of Consent to ulr-insum for Worker's Compere _
nation,as provided for by Section]TW of Ne Labor Code.for the performance of the -
we*for which Nis permit is issued.
❑1 have and will maintain Worker's Carepensuion Insuance.a real by Section
1100 of the labor Code:for she performance of Ne work for which this permit is issued.
My War ker'e CnmPenn jon Imus ce artier feed Policy number
CEKTIPICATEOFEXEh FROM WOR ERS'
COMPENSAI SURANCE
(This section need not he completed if the pcimit is for one hundred dollars($101)
or less.)
T certify that in Ne performance of the work for which this Permit is issued.I shall not
employ any person in any manner a as to become subject mhe Workcrs'COmpenaation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this CcrtiOcam of Exemption.you should
become subject to the Workers Compensation provisions of the Labor Code,you must
= O forthwith comply with such movininns or this vessel l shall be turned revoked,
Z ` CONSTRUCTION LENDING AGENCY
1 hemby affirm that them iaa mbtmctina lending agency for to performance of
Yr she.,it for which this permit is issued(Sec.309E Civ.C.)
iLender's Name
=z Lender's Address
J O 1 unify has I haw read Nis application and sum that see above information is
F COMM I ague to comply with all city and county ordinances and sale laws missing to
'U building construction,and hereby aut ire repmsenatiws Of this cityta enter upon Ne
N Wh 'hove-mentioned property for inspection purposes.
(We)agree m saw,indemnify and keep harmless Ne City of Cupertino against
r ray liabilities,judgmenu.cosuandexN.n hichmayi ywayammcagainnuid City
U F77 ineobequc Ne gremi ' per
APPLIC U DER IL C LY WIT LPO Issued by: Date
OURCE EG ATI S.
VMS Re-roofs
naurco Applican an Data
HAZARpO(IS MATER ALS DISCLOSURE Type of Roof
Will the applicant urfuture building cupar Iftme or handle harWaus material
as defined by the Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
coda.scenes]ssl:(.)y
T-1 Ya All roofs shall be inspected prior to any roofing material being installed.
Will the applicant so fwuu building occupant use equipment or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
it h turdna air mouladnanu u defined by the Bay Aro Air Quality Management all new materials fo spection.
auict7
CP
❑Ye$
I hew mad thehmardn mamrinls 'remema un der Chapmr6.95 ofthe Califbr.
nia Hcal"Safety 35 5577 d255)a.lunderswMNatifdmbeilding
dors nor dy o ate a my ma ad1xIa,ro notify Rte cuP us f o;
myuire u h' hmusl me 0 oissuancc of a Ccnific of Occu Ig I. II anl� Date
er or aatharid hiate All roof coverings to be Class"B"or better
f)
CITY OF CUPERTINO -0 3
REPIPE/SEWERS/MAIN SERVICE
• CUPEkTINO PERMIT APPLICATION FORM
APN# 47
Date: k
Buildin A dress: /� %/ /�
S.
Owners Name \
P ne#:
rJ EL1QA C Sp
Contrac r: on : Licens #:
Contac : Ph e: Cupertino Business License#:
IJ E -I D
Building Permit Info:
Bl Elect ❑ Plumb
Job ascription:
U KIr
Residential Commercial ❑
Cost of Project:
Qty. if
A 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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