05020020 I CITY OF CUPERTINO - sr✓ � mh "�' "� ""' " ;"':
BUILDING DIVISION PERMIT et
v .
a ILDINGADDRESS: - ABLE SEPTIC PERMIT No05020020
OW NER'S NAME: FERMn'ISSUE DATE
520 RRPT) RT
,ONE: SANITARY NO. OnAOL NO.
(408) 377-9990
ARCHOMCT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 t 0 0
Loo LICENSED CONTRACTOR'S DECLARATION - .
up I hereby affirm Nal 1 am licensed under provisions of Chapter 9(commencing Job Description
�W with Section 70M)ofDi ' on3 of be Business and Pro(essiwta Cede,md ray li,cmci,
5 Lice�«`Cahneerr "rail L¢.N 677 /7} PROPERTY LINE C/O
.p Date COmracmf &1617L
-iry ARCHITECTS DECLARATION
cU I unMuund my plana.hall IN used u public me.,&
u.o Licensed Professional
OWNER-BUILDER DECLARATION
f 1 besehy air.that 1 am uempt form the Canuavefa License Law for the
00 following moon.(Section 7031.5,Business and Poefessiov Cade:Any city or county
ym which mquuca a Permit to common,alter,improve,demolish,or repair any.muCwre
prior us its issuance,also ryuires Ibe applicant for such Permit o Me a signed statement
Escban IN,islicensed pursuant mthepmvisimotofbeConme.C.Uotese Law(Ch,tc,9 Sq. Ft. Floor Area Valuation
et- (commencing with Section 7")of Division 3 of the Business and Profusions out or
y Nat he is eacrept therefrom and the basis for the alleged exempdon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3_APMJQRl6bM 0 Occupancy Type
mot mart Nan five hundred dollars(S5u0). P Y YP
do
the work,and
property,or mycmes withwagautheiantic ,Busidon,
will do(e wort and(e suunum a rent intendednde,Lae does n t apSec.7o4d,Business
and enywhir bis Cade:The Contemns rad who Law dors or apply lf an owner of Required Inspections
ow neny who s,provided that such
and who me
work himacHor through his
own employee,provided that such impmsod with arc not intended or offered for sale If.
huilder,(ebuilding orden os smenti.hathwithinot year ofimprovforpurpose
upwonr-
builder will bass the burden of porting that be did not build w improv:for puryu c of
tile.).
C]I,a5 owner of the Sec.promarty,,m exclusively and conuacling with licensed mel eceirss to
i
mrmrucr(ens not (Sec.n in weer of and Prire,who Wion,lds
ds or i The Conuanon, rad
whoLaw doss not apply ti an owner of propcny who builds ar improv thereon,and
who contacts for such porjects with a convacros(s)licensed pursuant on de Conuactots
[krone law.
❑1 em exempt under Sec. .B h P C for this moon
Owner Date
WORKER'S COMPENSATION DECLARATION - -
I lumby affirm under pevlty of perjury oro of the following decimations:
1 have and will maintain a Ceoifcam of Consent 10 self-insum for Worker's Compere
mile ,u provitled for by Section 1700 of Ne labor Code.for(c per(onnance of the
work for which this pinnal is south.
-rave and will maintain Worker's Compensation Inaurance,as teyuired by Section
7700 of the Labor Cade,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance canner and Policy number am: ll /
Gardcr:S'�/�7't ro)" Policy No./356 P;-') '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section used not be completed if be permit is for one hundred dollars(Slip)
or less.)
I certify that in the performance of the work for which this permit is Issued,I shall not
employ any person in any manner sou to become subject to the Worker Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifieam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you most
.J z forthwith comply with such provisions or his permil shall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
Ihcmby affirm ban them is a construction lending agency l'or the performance of
Ca the work for which this pcnnit is issued(Sec.3097.ON,C.)
Q Q
Lender's Name
a. Lendeis Address
V 0 1 certify that 1 have read(is application and Sum that the shove information u
(—' corona 1 agmen m comply with all city and county ordinances and suet laws relating e
C.1 bundingenummil ion.and hereby au(omcapresenudvcs of his shy mcnmr upon the
}� above(We)agree
no saw.
for inspection keep l s
F O. (We)agree to save.and expenses
es kith harmless tbe City rwCoigns,against
fq incomanijudgmentc or eaosuand eapenua which may to any way accrue against said City60 1
V z mi
APPLLIICC N'r UNDERSTANDS ANDof WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGONS.
ate/ of J Re-roofs
Signamr App�)r'onall Date
cfHAZABOGUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haerhou5 muerial
as dented by be Cupertino Municipal Cade.Chapter 9.12,and(e Health and Safety
adlikode,Section 25532(a)? All roofs shall be inspected prior to an roofing material beim
❑Ye, EAl3�- P P Y g g installed.
Will the applicant or future bonding occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it haldous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
D'wria?
❑Yes �N
I have rt>V the haaar(ms materialsm iii mencou under Chapter 6.95 of be Califol
ria Helth S Safely Cade,Smtlau 25505,25533 and 75514.1 understaM that irdm building
does on,currently ham•tenant that it u my reapandhilily m notify tbe occupant M the
require hmhmtwx mpriormissuanmaoeenireamorampanry. Signature of Applicant Dale
All roof coverings to be Class"B" or better
o sum red m Dam g
Community Development
10300 Torre Avenue
{✓' Cupertino CA 95014
Telephone(408) 777-3228
�
CITY OF Fax(408)777-3333 UPEI�TINO
Building Department
JOB ADDRESS: PERMIT#
lc2.
OWNER'S NAME: Ea—L[+ Q l-4v9 v-�_7S PHONE # yv8 &33-76
GENERAL CONTRACTOR: Ll FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
Am Tile
OWU'W/Contractor Signature Date
1 �"� O o�CC";>CITY OF CUPERTINO OS a U
REPIPE/SEWERS/MAIN SERVICE
'® CUPERTINO PERMIT- APPLICATION FORM
APN# 3 7 I / o 3 Date:
-
Building Address:
02?() 13Z)/JN'' O/t.' Jam.
Owner's Name: Phone#: Y%�?
AL H Cv/7`4V4_ S s>93-76 f 3
Contractor: - Phone: License #:
LC
Contact: Phone: Cupertino Business License#:
(24dii G �)
Building Permit Info:
. -
Bldg-, ❑ Elect ❑ Plumb-
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description ' Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE 'Bldg.-Permit Fees -` - BUILDING
BPFIXTURE. Pb] . Fixtute--- - -- PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING