04060213CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTORA'FORMATION;�j
BUILDING ADDRESS:
WATER SYSTEMS PLUMBING
PERMITNo04060213
OWNER'S NAME:
PERMIT ISSUE DATE
NE:
SANITARY O. C N OL NO.
ARCHItECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I It rcby affirm that I am licennd under provisions of Chapter 9 (commencing
win Seedz7 91)uf Division 3 of Ne Businessand Professions Code. and my license is
�p
io full fierce and efleof. `86Z 4
C
REPIPE ,�L�D
Lureuc Class Lie, M
Da¢
AR HITECPS DECCAi OI
t
q
11!i 2
J l 2004
1 understand my plans shall used u p conds
�Il U ll����'tlp,�
Limmcd Pmfcmiem it
OWNER-BUILDER DECLARATION
eat 1 am from that Contractors License Law for the
I North,North,s17rm exempt
i following reason. (Semiun 7031.5, Business and Professions Cade: Any city or county
which requires a Permit to consumer, alter, improve, demolish, or repair any structure
! prior os int issuance. also mquirea the applicant fmrsuch permit m Glc a signed statement
nc Contractor's License Law
Sq. Ft. Floor Area
Valuation
tt
that he is licensed pursuant the pro0sions of
(commencing with Section 7000) of Division 3 of the Business and Professions Code)or
l don he is cumpt therefmm and then basis for the Jlegcd exemption. Any violation of
3 aro 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of
not mom than Eve hundred dollars (S5001.
0 1, as owner of rte property, or my employees with wages u their sole compensation.
Required Inspections
will do the work. and the structure is not intended moffered furcate (Sm. 7044, Business
and Professions code: The Conuanora License Law does not apply to ae owner of
propertywho builds orimproves thereon.andwho dommch work himselfortNough his
Own employees, provided drat such improvements art not mu:n hod oroRered formic. If.
however, rte building or improvement is sold within ane yea of completion, the owner.
builder will have rte burden of proving that he did not Wild or improve for propose of
sale.).
1, u Owner of the pmpeny, am exclusively contracting with licensed contractors to
consumer the pmject (Sec. 7814. Business and Professions Code:) The Com eacmr's Li.
caste law does not apply re an owner of property who Wilda or improvrs thereon, and.
who contracts for such, pmjecu with aconuactor(s) licensed pursuant to the Contmmo's
License Law.
1 am exempt under Sec. B k P C for this season
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of tt following declarations:
1 have and will maintain a CeNficate of Consent to elf-insum far Workeh Compen-
,mien, m provided fm by Section 3700 of the Labor Code, for the ne formanee of the
work for which this permit is issued.
1 have and will maintain Workces Compensation Inspranu, as required by Section
1700 of rte ° c, for the perform•yce of the work for which thio permit is issued.
°
'
My W. p+au�on/jd�lGrana eJ/ner antl Pollq num Wraura /t �7
Cady: N/o.` �t_
'✓✓✓✓ C RTIFlCATE OF E%EMP170N FR0 ORK RS'
ION
EXEMPTION
COMPENSATION INSURANCE
mais action need not becompleted if the permit is for one hun@cddollars (SIM)
'
or arca)
I modify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner n az to trome subject tort Winters' Compcnsmion
.
Laws Of Califomia. Date
Applicant
NOTICE TO APPLICANT: If, after making this CeniBeae of Exemption, you should
become subject to Ne Workers Compensation provisions of the Labor Gale. you most
C faMwith comply with such pmvisimis or this permit shall IN deemed invoked.
CONSTRUCTION LENDING AGENCY
1 hereby alarm that there is a eonsumcimm lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Under'. Address
s
1 unify that 1 hese reed this application and sue Net the above information mtatiat to
I ogre to city and and cute laws in
comply with all city and county obuivol
building c Of r upon
abovemgcenstrectimn.end hereby aunon purposes. rmivu of this city rocntcr upon de
above-mc e) agened propene for emnify ankeephst
(We) agree to save, indemnify and kith harmless the City Cupertino id City
in City
to
rLj liebilitiu.judgmcnu.ces and axpcnsca which may any way accrue against said
I S couequcrec ofth g ingofth' permit.
APPLICANT R AN D WILL COMPLY WITH ALL NO OI
Issued by: Date
SOUR S
zit yQ
a
ot gA
Re-roofs
S - ignara& or in ✓Co ctor Date
HAZARDOUS MATE ALS DISCLOSURE
Type of Roof
Will de applicant or future or some or handle haardous material
u defined by de Cupcnino Muni al . Chapter 9.12, and ON Hubris and Safety
Code.Section 15532(.)?
O yes P.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or deice. which
mit haaaNnm it contamin`ints u de0ned by rte Bay Area Air Quality Management
all new mate ' for spection.
District? f..'
❑Yes �h Pu
ffobii
YOwvl
uirementa under Chapter 6.95 ofthe Califor.
S
remmmgq'Lscupdoes t y res nsihility m nndly th acupan f rte
QW eam gr aCentric.te o uac.O
Sig Lureo pplica t Date
�
All roof cove ngs to be Class "B" or better
rte ter _ t omed.gent -CrDate
is
II
N,
CITY OF
UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS: /
1 77 tacc c
PERMIT # G 6
OWNER'S NAME:
PHONE # elo .2
GENERAL CONTRACTOR
FAX # Vb Z 339
FA
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
�•/Coni!
._..-
M
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
Tile
�•/Coni!
._..-
M
t
9
11
C
CUPEkTINO
CITY OF CUPERTINO z(3
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
APN # 3 6 A A `f
05-0
Dater �a YI
Building Address: �
w lam. Ghdi� 1.
PLUMBING
Owner's Name:
�i
)
CA4n
Phone #:
o2S3
Con 4 v
pY)t
f I,J � .j Phone:U� a 66 8��z
pad
License #:� g6 ?0 I
Contact:: Phone:
M,k� or ,r Z %2b Z5-
Cupertino Business License #:
Building Permit Info:
BPSEWER
Sewers
Bldg ❑ Elect ❑ Plumb Ef
BPSEWAGE
Job Description:
R5.-
PI r •d- ►iVl4ch L vhti
BUSLIC
Residential
Commercial ❑
Cost of Project: --.
5 bob
D lick le Fee TD
FPP DPSCrinti n
PPA (-rnl ,,
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
BUSLIC
Business License
BUILDING