03060129 y CITY OF CUPERTINO �}� �}y+ �.
BUILDING DIVISION PERTdd-'1P1TQ 11.1 Q� M .TYi
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emLDING ADDRESS: PATHENNEUSE PERMIT NO".03060129
• OW NER'S NAME: FEEMTP lJ`lA/ B/2 0
03
AT HENNEUSE,
JNE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
306 LICENSED CONTRACTORS DECLARATION
fJob Description
1 hereby affirm that I am licensed under prevision of Chapter 9(commencing
with Suction 70110).f Division 30f for Business and Professions Code.and my licence is
is fell force.adeHea REPIPE--2 BATHRMS amt aa�®
i yJ Z License Cleo Lic.N ,
-Contractor
a DateARCH,i DnON
I understand my plans shell be used aspub icMnxnrds J U L 1 4 2003
a¢ Licensed Professional
io OatIameUmptFoDECLARATION BUILDING
I hereby now .sere Net 11. exempt from tie Convenors License law for Ile
OO followingmann. emits 711in Business and Roeuinu Code:Any spy.county
$ which mquba a Permit roe ted the,epee Improve,demolish permit sere Pair any tte ent
-ZS^ poor"he iulesedpalsumq the NoappllaafmcCchocer'minese Law gned(Chapter
< Iharhetsliceued purant.thcpnoHalou of NeConuaceM1nd Prot ormCM1odter9 Sq.Ft.Floor Area $�'®Ig�jion
2C� tham he
exew[Srsficanadth Division ssf3.f alleged
Business tee ProfMyvi Code)or
g$ Net Ile 0 exempt Illemfrom and the EesY for dx allejed exemption.AnY violation of
Section 7071.5 by say applicant for a permit objects Ne applicant to a civil penally of 3 AIDN NOdifier 0 0 Occupancy Type
not mom than five hundmd dollars($500).
❑I,uownmoftepmpwy„mmywplaycawbhwguudei mlemmpeeadna,
wllldo Nework.end Neawnu.bmtintended moRered(orale(Sec.7011.Businss202 - dd
AndR.feWaN Code The C.naanara UnionistLaw dna Out apply m n Owner of 301 - ROUGH B
property who builds.improm themon.and whodoessuchwork hinsa forthrough his
awnemployees,provided thauuch improvements am not intended compared ser Aide.If. 502 — FINAL PLUMBING ENERGY
however,Ne building or Improvement is sold within one year of mmpktion.the Owren
Wilda will how Mel.udnofproving Mat ledid act build«Improverorpurpose of 507 - FINAL PLUMBING
axle.).
❑1,As owner of the property,am exclusively convecting with liarneed conven.m to
monomer the project(Sec.7014,Business and Pafessl.0 Code:)The Consumer's Li.
mum Law does not apply in an owner of property who builds or impmres thereon.son,
who mauves for such projects shut a contractors)licensed pursant in Me Coaysomrs
Limes Law.
ordersm
this
kgerPyt .r.l 4 .Bk PCfa
//iA 4 int, Dae. 0..3
WORKER rS COMPENSATION DECLa
I hereby affirm coder penalty of perjury can of the following dmlNtiaN:
1 hove and will maintain a Cardinale ofC.nw.t esleW...for WorkcrsCompen-
103700.f
on,u provided fm by Section 37M of the labor Code.fee the performance of N.
k for which Nis permit is Issued
RJpFlQN
1 have and will munain Worker's Compensation Iosuremc,u required by Section
Ne labor Code.for tie perfosmarme of Ne wmk for which Nis permit is issued.
Workers Compenation Insurance copier and Poliry number am:
pim: Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Cfbb Auction recd cot becompleted if the Permit is fmonbund.ddollars(SIM)
or ksa.)
1 autifY Nat in Ne perfn gree of the wart far which Nis Mrmir b issued.I shall not
mnploy nype ren 4nnneCr}pao� LE mbjeci to Ne Warkere Compensation
Laws of Celifq�a r . /
Applicemsdjf(JJ Al 1'':��
NOTICE APPLICANT:If,after making Nb Certificate of Exemption,you should
become eco a Ne Workm'a Compensation provisions of de Labor Code,you mute
=O foMwith comply with such provisions or Nb Permit hall thisdecmcd noncom.Z 2CONSTRUCTION LENDING AGENCY
I hereby affirm Mel tie.b e comnl.ctinn lending gency inn Ne perfumtsvm.r
x Ne work for which Nb permit to issued(Sm.3099,Civ.C.)
1 Q lender.Name
Z Leader.Aldram
J O 1 mnify that 1 haw mad this application cod sus that the Above information is
y coarct.1 agree to comply with all city and county ordinances nd stain Iowa relating to
Wilding construction,and hemby nNmi.representatives Or this city to enter upon the
C shove-mentionedm
ppeny for impecoon purposes(ft)agree a sow,indemnify and keep hummu ft City of Cupertino against
L.y liabilities,judgments,core and expenses which may in coy way accrue against said City / 0=
J T in consequence of the granting of this permit. I/ (/(/)1
C-m APPLICANT' of
AND WILL COMPLY WITH ALL NON-POINT Issued by:9 D
SOURCE RECULATIQNs. /
cs Re-roofs
of Appli HAZARDOUS MATERIALS DISCLOSURE Dete Type of Roof
Will Ne applicant or future building ucoupnt store at handle hazardous material
ss MOrted EY tie Cupertino Municipal
C.
Chapter 9.12,and the Hc.IN and Safely
ods, 0 Oursss32(.)T All roofs shall be inspected prior to any roofing material being installed.
QYea f1 No
Will the Appvant or mm.building mcaPIAL ase equipment or devma which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as dcMcd by the Bay Ara Air Quality Management all new materials for inspection.
inict7
O Yes �No
I haw mad thehneadousmawdab mquimnenu under Cluper6.95 or Ne Califor-
niaHco[&SafciyCo .SwdmA25305,25533nd25334,1undcrstandthniftie building
Jou not curmntly haw a tens.ear to b my mspomiNlity mdfy the Occupnt of Ne
requimments which most el pdm a issuance Or.cemlka am Signature of Applicant Date
G
Owner ter nthorized agent Dote All roof coverings to be Class "B”or bC[Iei
CITY OF CUPERTINO
` REPIPE/SEVERS/MAIN SERVICE
�CUPEkTINO PERMIT APPLICATION FORM
APN# _ Date:
d
Building Address:
CU ZIhJ nu-e
Owner's Name: Phone#:
H e (X-) tie ?73- /402
Contractor: Phon License #:
S ,e x'73- / 402
Contact: Phone: Cupertino Business License #:
B m rmit Info:
Bld Elect ❑ Plumb Z
Job Desc ' tion:
Residential ❑ Commercial ❑
Cost of Project:
• � CJ
Qty. i
AppVc'1!tb1"6 Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
PPERMTTFEE 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
zz �° 7
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