04010006 CITY OF CUPERTINO
BUILDING DIVISION PERMIT I CONTRACTOR INFORMATION
BUILDINGADDRESS: CUPERTINO PLUMBING PERMIT NO 04010006
q4 RT.A7.TN(-WOOn AIT
1 OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
300 LICENSED CONTRACTDECLARATION
tl FF I hereby affirm than 1 am lianxed underderprovisions of Chapter 9(commencing Job Description
SZa� with Section]oflU)of Division Stribes Busiricass and Pmfcuium code,and my license is
n,� in fours, and efren.
zqz icen,ecl �=3 � Lk.g 2 t 5' REPIPE/WATER SERVICE/WATER HEATER
Date �a,J. �Contnctor y//!1
q ARCHITECTS DECLAR ION
a 1 undersand my plans shall he used as public records
.1,
T a0� Licensed Prefe umMud
OWNER-BUILDER DECLARATION
<X 1 hereby affirm that 1 em exempt from the Constitute.Lima.law for the
00 following mason.(Section TO 1.5,Business and Professions Code:Any city or county
$ which require a permit to cnewcl,aW,,improve,demolish,Or repair any annum
poor In its issuance.also requires Lhc applicant for such Permit to E lc a signed statement
nnn_
C that W is licensed pursuantto Ne previsions of NC Contractor's Lime law(Chapter 9 Sq.Ft. Floor Area Valuation
a (commencing with Section 7W0)or Division 3 of the Businessual Pmfesimua Code)or
dust he is exempt therefrom and the bass for the alleged exemption.Any violation of
Section 9031.5 by any applicant for a permit subjects She applicant m a civil penalty of 3 B�1N-TUIIDbCrO 0 Occupancy
not more Nan fin hundred da0a.($500). T'Pe
❑1,u owner of the property,or my employes with wages as Noir sole compemallon,
will do the work.and Ne awctme Is not intended oroftemd fork(Sec.]044,Blssine.
and Poorest..Code:The Convector's Liceme Law docs not apply m an owner or Required Inspections
property who buildaur improve thereon,and who doessuch work himself orthrough his
W...,,toyee,providedthmsuehimprovems,nlsanue year.fedmi.md themaex- +
hasildm Ne building ar impmvem,iag soldwiNinom)earofeompletion,Neowmr-
builder will have Ne burden of proving Nm he did nm Wild or imprnw for purpose of �.
sale.).
❑I.as owner of the property.am exclusively contracting with licensed condition m
cnmuuct Ne project(See.70Business and Busiand Profasiom Code:)The Convector]U.
cents Law dots not apply to an owner of property who Wilds or improm thereon.and. I
who contra for such pmkcu with a contractor(s)licensed pursuant o the Contractor's
Laemse law.
❑1 em exempt under Sea .B k P C for Nb moron /
Owner Dau
WORKER'S COMPENSATION DECLARATION '
I hemby afBmr under actually of perjury one of the following declanlions:
I haus and will missile a CeniOeua of Consensus self-iusum for WorkcraComposts.
sailors,u provided for by Section 37M of the labor Code,for she performarca of the
work for which this permil is issued.
I have end will maintain Wnkcr's Compcnsstlon leunna,is mquirttl by Suction
3700 of She labor Code,for the performance of Ne work for which Nis permit is issued
My Worker's ComlPnusom once carrier end Policy number am:
CAM": I Policy No.: 6DO�� U/
O
CERTIFIC TE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thusalon needrroHmcomplemdifthe lermhisforoneh oulumdnllan(SRM)
or ksa)
1 certify Nat in the performance of IW work for which this Permit is issued.I shall not
employ any Person In any manner an as to become subject o the Wo luCOY Compewtion
Laws of 6likeraw Data
Aprilan,
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
beams,subject an the worker's Compensation provisions of the labor CMe,you must
0 O forthwith comply with such provisions or this permit W deemed marked.
r .. CONSTRUCTION LENDING AGENCY
[—r Ithereby whichom Net Nem isacoMmninnknding agency fnrdm performance of
Le work for which this permit is issued(Sm.3097,Civ,Cd
W� Q Leader',Name
Add
Z)z Lender's Address
U Q I certify Nn 1 have read this application and rete Nat She above Information id
u,f-s corm4Y 1 agme to comply with all city and county ordinances and auto laws misting to
DU Wilding cmswction,and hereby authorim represenutl oftnuckywemeuponthe
4 ahove-mcritioned pr*rlyJm inspection purposes
(We)a Tee to aLm indemnify'md keep kat she City of expert against
E' V1 liabilitie,J�dgmecoals antl'expenxes which in anywry mane againatseitl City
U Z In canary cp Nq(rantinL of,t ' 1962r,
ti
APP IC fjT'fl DER u( A +WI WITH ALL NON-POINT Issued by:S Date
SOUR R
5 t Re-roofs C7 L
`gnaw a pplicaHAZARoou DISCLOSURE DateType of Roof
ill Ne applicant or future buil 'ng acupanl atom or handle haaandous material
u dented by tW Cupertino M cipal Code.ChaPkr 9.11,and the Health sed Safcry
Code,Sadao 3asRla)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the applicant o future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
dl hourdnus air conarmonts denncd by she Bay Area Air Quality Managcmenl all new materials for inspection.
i'vict7
❑Yet
/// o
I ad Ny ba /m Isla mquimments under Chaptarts of Sm Califor.
ma"cul Sof y ,Sec 25 05. 533 and 35534,1 mudenWd Nu if dm Wilding
dawn slysyete ' it' my reSprouldhiffitY m nadfy the ooeupant ofthe
mgaii w is a pd an accmheteofOccupancy. Signature of Applicant Date
Ow u tolmn d a cot Dam All roof coverings to be Class°B°or better
1
CITY OF CUPERTINO
' REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO ! PERMIT APPLICATION FORM
J
APN# l _ I ' I r] 0 1 1
Building Address.. lg&z /%V
Owner's Name: mark m�� Phone #: /
PAI
Contractor /-70
Phone: License#:
Contact: ne: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb>6
Job Description:
Residential C ercial ❑
Cost ofoject: SGC,G
Qty. if
Appec—able 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
BUSL Business License BUILDING