03080098 CITY OF CUPERTINO
,
BUILDING DIVISION PERMIT CONTRA.C-,TnR INFORMATION*
,fuse�+ ^ixnYvs „ 1v a.,•':.
eoaol"cnDDRess: CUPERTINO PLUMBING 11111 rf'03080098
OW NER'S NAME: 10297 S DE ANZA BLV PERMITISSUEDATE
G"E` (408) 253-0618 SANITARY NO. CONTROL NO.
ARCHITELTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MLCH
j00 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am limneed under previsions of Chapter 9(commencing
� I� with Section 701k).fDivid..3uf Ne BusineMitid Professions Code,and mylicense is
H in full fo a cad effect
i�z License fp
! �3L Lic.g Z id COPPER REPIPE yy jj qq
I- Dam C.ntti= SEP 1(' 2obJ
\ ARCHITECTS DECL; �5 ON
1 1 undcrplg�rs'my plans shell W u+eJ as puQlj(re
>jU
ea cords
Licensed Professional
-U OWNER-BUILDER DECLARATION BUILDING
I I hereby affirm that I am exempt from the Contractors License Law far the
fallowing reason.(Section 71171.5,Business and Professions Cale:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
uZC prior Bs its issuance,also requires the applicant for such permit to file a signed statement
mm< thatW is licensed prominent to the previsions of the Comracmri Lunare Law(Chapkr9 Sq.Ft.Floor Area Valuation -
[F� (commencing with Section 7000)or Division 3 of the Business and Professions Cook)or '
9 'hat he is exempt Nemfrom and Ile bull for the alleged exemption.Any violation of 35623047 . 00
Semon 7071.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more Nen Five hundred della.(S500).
❑Luowner of the propeny,mmy employees with wegesu Heir vele eomlenmion,
wdldo Newark.and the+wctureisnminendedoroQered(.,age(See.7040,Busiw+ — ��q Ct10DS
and Profession+Cade:The vesOcriContractor's
n, cad who Law dins not apply to+n owner of 5 02 - FINAL PLUMB IN ENERGY
pmpeny who builds or improves Nercon.and who dm+wch work himself or through his
ownemployms,provided lhusuchimprovemene arenot intendedorottered forssle.IL 507 — FINAL PLUMBING
however,the building or improvement is suld within one year of oempletion.Ne mome.
Wilder will rave de burden of proving Nu he did not build or improve for puryom of
tile.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
convect the project(Sec.7040.Business and Professions Code:)The Contractor's Li.
come Law docs not apply to an owner of property who Wilda or improves Neuron,ad.
who conets for such projects with a eontramor(q licensed pursuant to the Contractors
License Taw.
❑I am exempt under Sec. B A P C for Nis rtuon
Owner Date
1307CWORKER'S COMPENSATION DECLARATION
I hereby if llon under penalty of perjury ore of OR following daclanith.
I have and will induced.a Cenifimt.or consent o self-insure for Workers Compere
M
ionr u provided for by Section 7700 of the Labor Code,for the performance of the
W
for which this permit Is issued.
I have and will maintain Workers Compensation Insurance,u required by Section
of the labm Code.for the performarmcc of the work for which this permit is Issued.
yWork ' C�mpensaIion lnsu.nttm icr andPolicyyo thicram:errs�rAT� IVN� icy No,:f .� LL7
CERTIFICATEOF EXEM NFROM WORKERS'
COMPENSdT NINSURANCE
(Thisseclion need not bccomplced if the Permit is fnronc hundred dollars(1100)
Mss)
1 certify OR,in the performance of the work for which this permit is issued,l shall not
employ any pawn in any Warner an M m become subject o the Worisms Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Cent ream of Exemption,you should
become object to the Worker's Compcnwtlan proWions of than labor Code.you mum
.JO forthwith comply with such proviime or Nis pe mon MI W doomed rooked.
z .rN., CONSTRUCTION LENDING AGENCY
(-m I hereby affirm Nat there its convection lending agency for the Performance of
Ne work for which this permit Is issued(Sec,3097,Civ.C.)
aQ L mdcr9 Name
z Lender's Addre.. _
V O 1 ttnify that I have mad this application and+tie that Ne shove information is
coned 1 agree to comply with all city and county ordinances and state laws relating N
building construction,and hereby auhorim represenmiver of this city to enter upon the
{17 above-mentioned property,agree to sufor Notion pts s.
(We) ve. d oifyaa0 p less the City or Cupertino against
`.y n fialoittics,judgments,coulds e tau ich y in any way accrue quid Mid City
V 4
in APPLICANTe of the o g StAs IL PLY WITH ALL NON-POINT Issued by: Date
sou ce c
te GRe-roofs
urc Applian C.nmc Date
HAZARDOUS TERI SDISCLOSURE Type of Roof
Will the applicant.,future bud c.part store or handle baraNuus..Wool
u dented by the Cupertino Municipal Cade.Chapter 9,11.and the Health and safety
Cole,"CCU
EI yo
15531(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Wi11 the applicant Or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
nil haMrdous air coneminams M di by the Bay Area Air Quality Management all new materials for inspection.
Strict?
❑Yin Nu
Ih.vc mad the M usmatedal quire qts under Chapter 6.95 of the Califon
nix Healith Safety olio 5 , 5J) 1255 .l c.wnd Not lfthc Wilding
docs col cumend ren Ih my spun to modify Ne-cecapmt of the
mquncon, s fila cnlBc+eofDc` Signature of Applicant Date
o t .d.gcnl x''bow All roof coverings to be Class "B" or better
r
CITY OF CUPERTINO o 9�
REPIPE/SEWERS/MAIN SERVICE
CUPEIkTINO PERMIT APPLICATION FORM
AIN# Dater
Building Address:
Owner's Name: c ��w r Y� Phone#:
J r7
ontractor: G P one: Lice s
P L 6! b� ZS (tel � y�I6S—
Contact: ho e: C pertmo Business License#:
K C' in s vcn i i �-
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: pP )t0'6TL ?C-
ResidentialCommercial ❑
Cost of Project:
'Jv�LJ
Qty. if
ApplicArkble Fee ID Fee Description Fee Group
PPERMTI'FEE 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