03110043 s
. CITY OF CUPERI'INO
BUILDING DIVISION PERMIT CO,NTRACTORIIVF[JI2MATIDNz,
euILDINGADDRESS: CUPERTINO PLUMBING PERMIT NG03110043
2 7
OWNER'S NAME: 10297 S DE ANZA BLV PERMITL4UEDATE
ROY GOLDMAN 11/10/2003
NE (408) 253-0618 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
liopLICENSED CONTRACTOR'S DECLARATION
t� 1 hereby affirm the,I am licensed under provisions of Chapter 9(commencing lob Description
s� wit Section 700r,pf Division 3 of to Business and Professions Codo.md my li"rtes is
of inrmlmmeand et. J/ Q REPIPE & WATER SERVICE
jg? Lkenu lou Lk.rMaARCHIT CanE-),, N®
! DaWr
�undcrsund my PI
ata hal M usedOahpOfill�nrds
r Licensed Pmfcssional NOV Swg OWNER-BUILDER DECLARATION 2 ` ZOOp
I herchy affirm Net I am exempt from tW Conmetor's License Law for the a7
00 following mason.(Scedun 703 1.5,Business and Professions Code:Any city or county
Sq which mquir"a Permit to construct,else,improve,demolish,or repair any structure 0 0 0
diy prior in its issuance,elan runtresthc applicant for such Permiuo Glc.signed mucamatrig
poppQr�< that he is licensed pursuant m to provisions of the Contractor,License Law(Chapter 9 Sq. Ft.Floor Area ff�Slr
CSS (commencing with Section 7")of Division 3ofthe Business and Professions Cnda) 32613059 . 00
Q
that he u eumpt themfmm and the buts for da:alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects to applicant an a civil penalty of APN Number Occupancy Type
not mom Nan Eve hundred dollars(S500).
❑I.as owner of the pmpeny,ar my employees wit wag"As Nair sole compensation,
will do to work,and to❑mctum is not intended or offend for sale(Sec.7044,Business
I ' and Prof"cions Code:The Contractor's License Law does not apply to an owner of Required Inspections
proper who builds or improves hereon,and who doss awh work himself or trough his
own employees,pmvidcd that such improvement,arc nulinunded or offered formic.If.
however.to building or improvement is old within ane yen of mmpktion,he owner.
Wilder will have the burden of proving tet he did not Wild or improve for purpose of
sale.).
It ❑I.as owner of to pmpeny am exclusively comoming with licensed contractors to
construct the project(Sec.7044,Business and Prof"sions Code:)The Contractor's Li-
cause law does not apply to an owner of property who Wilds or improv"Lemon,and
who contracts for such project,with a conv.cmr(s)licensed pursuant o he ContractoM1
License Law.
❑1 am"crept under Sec. .B&P C for this roman
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby sffrmr under penalty of perjury ane of the following dalsations: -
I navicend will maintain a Certificate of Consent eno self-;nouns for Wader'sCompun-
uties,ss provided for by Section 7700 or the Labor Code,for the Performance of he
or which his Permit is issued.
w 1 w and will maintain Worker's Compensation Insurance,u required by Senion
of labor Code.for to performance of he Durk for which his permit is issued.
M,yL�Woo-r�kler's Compensation Insurance carrier artCslolicy nnuumtheer artr�
CV JE I EMPPolic FROM WORKERS'
COMPENSATION INSURANCE
(This sectism need not tocompleted if the hermit is for as hundred dollars(SIM)
leas)
I unify hat in the pe f.hamee of he work for which his Iacrmit Is loved.1 hall nm
employ any person in any manner An As in become subject o to Worims Compcnsnion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifieam of Exemption,you should
Wcome subject to the worker's ComlMnution provisions of the Leber Code,you must
7z fonbwih comply with such provisions or to Permit hall bo deemed mwked.
ti y CONSTRUCTION LENDING AGENCY
I hereby aMr.hat dare iso cmuwetinn lending agency In,the ive fmmm e:of
Z he work for which this permit is issued(See.3097,CO.C.)
!t] Q Lenders Name
= z lender's Address
V 0 I Cenify Nat 1 ban read this application and sate that he above information is
lU ;'" COMM 1 agree to comply wit all city and county ordinances and sum laws relating to
0 rV' building consinution.and hereby AU006M reprelonutiws of his city to enter upon he
IA1 above-mentioned property for inspection purposes.
gy (We)agree m u indemnify and keep harmless to City of Cupertino against
In liabilidesjudgmcnu osu and a h may in any way uauc against Asia City
V in conuqucnc cpfemi gfive it, L�
APPLICAN DLRS NDS W L COMPLY WITH ALL NON-POINT Issued by: Date 41
SOURCE R
Re-roofs
nun ApplicanUCam to Data
HAZA DOUSMA RIAISDMCLOSURE Type of Roof
ill W.Pplicmi ser u u ding acupamamm orhandlc hpsrdous mamrial
As de cd by to Cupen' Municipal Code,Chapter 9.12.and he Heath and Safety
od,�perc.zss3z(an u All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant esu oqulpmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It W.Wous air conuntinanu u dcOncd by he Bey Area Air Quality Management all new materials for inspection.
District?
Yes � u
I hew ad in a�ado maser; smsj menUundcrChapmr695.fteCalifm-
m.H"Ih& Afel o"25 5.25 3 23534.IundcmandhvifdahuiidmS
does not c nl awe rant; It if monsibility in nndl'y the oc,aum of to
myuimm n nth a u ac nca6z&7P,ncy. Signature of Applicant Date
w ar gen �J D,k All roof coverings to be Class "B"or better
CITY OF CUPERTINO 62
REPIPE/SEWERSIMAIN SERVICE
CUPEII;TINO PERMIT APPLICATION FORM
APN# � �� Date:
Buil3ding Address:
2275
O=Name: O/ Phone#:�i 22 2
Contractor: Phone: License#: C�
253DCol� ?C y
Co act: ne: Cupertino Business License#:
��k Cardia lgl Coit
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: i
r c, L,> c ✓ rvl
Residential 11�p _--Mramercial ❑
Cost of Proje
•
Qty. if
ApplW&e Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe 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
�3 � 3