03050100 CITY OF CUPERTINO >11- 114. 1( ^� �yy ye-�!'� 1 J�' �" E ` "' 1V
BUILDING DIVISION PERMIT `�+TLs+ �Tv� Y ' ATY1� r -
BGILDINCADDRESS; DOYLE CUMMINGS PLUMBING PERMIT No.03050100
OWN
ER•s NAME: 14311 . BUCKNER DR PERMIT ISF?A7/L 52/2003
NE' 4089234221 SANITARY NO. CONTROL NO.
ARCHITECT/EIOGINEER: BUILDING PERMIT INFO
BE ELECT PO MECH O
jOo LICENSED CONTRACTOR'S DECLARATION JobDescription
I1 hereby affirm Nu 1 am licensed under provisions of Chapter 9(commencing
dF with Section 7000)afDiNdon 3 of the Businon Processions Code.and myllcenm is
3� IL ma",as �` a S5 REPIPE (2 BATHRMS) /WATER HEATER W��� �I I�tI��
D SO RATION P/I FB" `-'ALLSO
1 I undC=nd MY plans"I W um public records
777
a� Licensed Professional MAY 2 9 2003
OWNER-BUILDER DECLARATION
I hereby dRml that 1 am exempt from the Contractors License taw for the
.00 following reason.(Section 7(D 1.5,Business and Professions Code:Any city or county
S$ which requires a permit se...L,alter,improve,demolish,or repair Any atmqum R1 III nING
prior At its Issuance,also requires We applicant retouch permit to Rte ulgned statement
mathe lstim mdpumanitomepmvielomofft Cm wr'sL.tean:claw(Chapter9 Sq.Ft. Floor Area $3 �I8tion
om
C � (cmencing with Seedon700Aof Division Sof the Budness areO Profession Code)or
tt $ WI he Is exempt therefrom and Am basis for IM alleged exemption.Any violWon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pemhy of 3 MIJl 011nbev o o Occupancy Type
not moa than five hundred dollars(WWI
❑I,as owner of the pmputy,m my employees with wage As theb sole compensation,
will do thewoh,and the structure Is not inaMed or offered fm some(Sec.7044.Business — d$� G
Add Prore aiam cane Toe cea actor.uecnse raw area oat apply to an owne or 301 - ROUGH PLUMB I
propenywho bulMsa improwithereon,antl whotlaesauch wort himxelf or Wougb
his
Own employee.provided thatamh improvements amnot Intended neoffmed forsak.If• 502 — FINAL PLUMBING ENERGY
however,the Wilding or Improvement is sold within an year of cempledon,the owner-
bulMet will have the border of proving mat hedid not buiWorimprove far purpose of 507 - FINAL PLUMBING
sok.).
1,As manor of the property.Am exclusively contracting with licensed contractors to
camwct the Pmjca(Sec,7044,Business and Profedans Cade:)The Contractors Li.
MM law does not apply An an owner of property who builds or improves Netan,and,
who contracts for such project,with aeonmctor(s)licensed pursuant to the Contnttars
Llem m Law.
❑l Am esempt under Sec ,B&P C for this mason
Owner Dam
1037. WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemlty of perjury urn of the following declaruiom:
I haw and will mdnW n a Cmtincau of Concent to self-insure for WorkersCamPM-
0
on,u provided for by Section 3700 of the Labor Cade,for the performance of tha
k for which this pmmit u issued.
1 have and will maintain lVmscrs Compensnlon Insurance,u required by Section
0 of the labor Code,far me pufaremoce of the work for which Nis permit Is issued.
W°j�cera Compensation lnsutarum artier Intl Pali nu barart:Pollry N : fA C).05 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
moutaccdon need not becempletedifthe permsUs form hundreddellars($100)
or leo.)
1 certify that in the performance of the work for which this permit Is iumtl.I Ahdl not
employ any person in my manner m as to become subject to the Wori eri Compensahon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Certificates of Exemption,you should
become subject to tits Worker's Compensation provisions of the tabor Code,you most
Z, foMwith comply with such provision or this permit shell W deemed mooted.
'Z O CONSTRUCTION LENDING AGENCY
[.r Ihereby.M.met there iso crmtmclton lending agency fat me Performance of
Ci the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Landers Name
Z)z tubera Addres
fJ Q I certify that I haw toed this application and state that the show information is
Drs armeL 1 agme m comply with all city and county ordnance$and Nm laws mlating he
(7 Wilding combustion.and hereby aumarim repmunudwa of suis city to crew upon the
W sbove•mcmiorod pmpeny for inspection purposes.
(We)Agree m saw,indemnify and soup homeless Om City of Cupertino against
Imbilifice.judgments,costs and expense which may in any way accrm gdnst said City
in consequence of the graming of this permit.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOURCE REGULATIONS.
�cts 5•Qa-"d Re-roofs
u ofAppliesumnContractor
HAZARDOUS MATERIALS DISCLOS Dau Type of Roof
WIII the appldant m forum building occupant atom or hands hvodom materiel
a$de0ned by the Cupertino Municipal Cade,chapter 9.11.And the Hedth and Safety ,
ode.Sc❑cYG 15572(a)? No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contsminsne u&Mod by the Bay Area Air Quality Management all new materials for inspection.
tunct^7
❑yes �Nu
I have mW the husrnus mauri ils requirements under Chapter 6.95 of the Califor-
niaHealth AtSafetyCode.Sectimts15505.25533 and 25534.1 understand men it the burning
does rut currently have A tomo then is u my ility m coury the occupant of the
regdreme whichmunmmetpoor=MynFaef. 'MAteofOccupsury. Signature of Applicant Date
5-a- 03 All roof coverings to be Class'B"or better
Owner o authmired agent Dam
1
CITY OF CUPERTINO S-
��" REPIPE/SEWERS/MAIN SERVICE
�CUPERTINO PERMIT APPLICATION FORM
APN# 2-&)— �J L Date:
Building Addres
.0 A2-1 r1q We-5-1
Owner's Name: / ,N Phone#:
Contractor: Phone: License#:
17 , CUkn m> n 5 I w m bi n q , ctd3- - /
Contact: Phone: Cep/ Cupertino Business License #:
fn ak iaa ' 2 l� og a3- as t
Building Permit Info:
Bldg ❑ Elect ❑ rPlumb4;
Job Description:
//�
Residential dimercial ❑
Cost of Project: Lp
/P 3
Qty. if
Applicable Fee ID Fee Description Fee Group
BP5RMFFF, Bldg. Permit Fees BUILDING
w
lIzalu
PPERMITPEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING