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CITY OF CUPEWrINO
CONTRAC°�TOR INFORMATION `',
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
CUPERTINO PLUMBING
PERMIT NO.
04040018'
OWNER'S NAME:
PERMIT ISSUE DATE
8 S
)NE:
SANITARY OL NO.
CHITECT/BNGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions or Chapter 9 (commencing
n]org)of Division 3af Nc BYsInensW Prmkssimrta Codc, and mylicense is
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REPIPE/WATER SERVI �(F /�`�J�1�TILHp/Li-\\\Yrµp{�p�j67L$�l(�FVy\/�
lass Lk.
Dau C'S
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ARCHITECT'S DECLAMATION
I understood my plms.hall he used as public .cords
O 2001
f, Y a
NOV� L
Licensed Pmfcssi... I
OWNER -BUILDER DECLARATION
1 herthy affirm Ilial 1 am exempt from the, Comunwhors License law for the
following mason. (Section 703 L5, Business and Pmfcssioru Cale: Any city Or money
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which die ire. a permit w construct, alter. improve. demolish. m mpalr my structure
prior to I% issuance. also requires the applicant (or such permit to file a signed statement
Sq. Ft. Floor Area
Valu a[ on
that he is licenced putum the proContractor'svisioor theContractor'sLimmc Law (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
Nat he is calmer Nerefmm and de basis for the alleged exemption. Any violation of
32W4U}94er00
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of
not more than five hundred dollars (5500).
❑ 1, as, owner of the property or my employees with wages as their sok compcns.tion,
Required Inspections
will de the work and Neswcture is rte, intended or offered for safe (Sec. 701 Buttress
and Profess on" Code: The Concession's Limnse Law docs not apply un an owner of
propcny who builds mimprovea thereon, and who doessuchwork himselfor through his
own employees, provided that such improvements are notinuendW oroffered for sale. If,
however, the building or improvement is gold within one year of completion. Its, owmer-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
T, as owner of the propend, am exclusively contracting with licensed contracwrs to
construct Ore project (Sec. 7044. Business and Processions Cade:) The Conumser's U -
me law does not apply out an owner of property who builds or imposes Income, and.
who contracts for such projects with a conuectods) licensed pursuant to Ne Contractors
License law.
❑ Tamexcmptunda Scc .Bk PCferthisousen
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ile following declarations:
-
1 have and will maintain a Cedifmo of Consent to sclr-insure for Workers Compere
satimn, as provided for by Section 3700 of on labor Cade. for Ne perfonmancc of Ne
won for which this permit is issued.
have and will maintain Wortrr's Compensation Iruurance, as required by Section
7)0 or the labor Code, for the performance of Ne work for which this permit is issued.
My Wmrkce nm nca . a lamer and Polity art: //--
/m,�unsber
/
Cnod 'G Macy No.W n � t% �i l�
CERTIFIC TE OF EXF1d Pf10N FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section recd not Inc completed Bribe Permit Is (atone hundred dollars (5100)
or lex.)
1 certify that in the perrwmencc of the work for which this permit is issued. I shall am
employ any person in any mannerso 0 to become subject n the Workers' Compensation
laws mf Califomia. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Ccnificau of Exemption, you should
become subject in the Worker's Compensation previsions of the Labor Code, you must
' fort iN comply with such provisions or Nis permit shall he dcemed mwked.
CONSTRUCTION
edun leading agency
hrudey Nn Iliac is•co Icnding agency Icer tie perfurmance of
which (Seen
' the work for which Nb permit is issued (Sec. J09], Civ. C.)
jlander: Name
Lenders Address
1 certify, that 1 hall read this application and stair Nal the above information is
' correct. 1 agree to comply,with all city and county Ordinances and sure laws relating to
buildingconwuction.andbcmbyarmhomeopasenuti 'ofthiscieytocnurupnnde
.hove- mend mde4 pmpiny for ivpttuon purposes
(Wc) V. ro save, indemnity aritl keep est the City of Cupertino against
'co
j liabilitles,judgmegU. costa Arid C. which in any way seem against said C�ly
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' in C.rtsu(ocpif Nc granting or slermi1*
L AhrC/jUND RyJ'q D ND W IL OM TH ALL NON -POI
Issued by: D e
SAPPOU1-7
GO
—
Re -roofs
Type of Roof
gnnure fApplicanUCmnoactor Dale
HAZARDOUS M A DISCLOSURE
I Will Nc applicant or future building acupmt score or handle harardous material
as efncd by the Cu renum Municipal Code, Chapter 9.11. and the Health and Safety
Code. Section 25331(.)7
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All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
.,tit haranum, air contaminants as defncd by the B y Amo Air Quality Management
all new materials for inspection.
District?
dyes u
ne me
Ihavv�maJ the liar Iws mater"la reyu unikrCWpurQ95ortWCalifor-
niaHcol Salfy ode ussV25 ,25 SJd.lunderxand NuirNC Wilding
dose ten a a u t, - it' on rwuly tW occupant orthe
myairt e m o cemn fe,m furanry
Signature of Applicant Date
All roof coverings to be Class "B" or better
wn or.athmrived .sent Dare
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
S-/
PERMIT #
OWNER'S NAME: -o
PHONE #
GENERAL CONTRACTOR: er h
W # -75 7
' 1,- - J
I am not using any subcontractors: '/ 5 -
Signator Date
Please check applicable subcontrac rs and complete the following information
.+ -. .�fe-'
Date
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
She t Kock
.+ -. .�fe-'
Date
•
F
arr OF
CUPERTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
-5TOml
APN # J 2(/ _ L43 U S
j Plumbing Permit Issuance
Date: Lj
Building Address:
�a��; C�sfine
1�v
PLUMBING
Owner's Name:
LO" 4
Bldg. Permit Fees
Phone #:
1?0/
Contractor:
P ne:
40
License #:
W -L190-5
Contact:
Phone:
&00)
Cupertino Business License #:
Building Permit Info:
Sewers
PLUMBING
Bldg ❑ Elect ❑
Plumb IJ
PLUMBING
Job Description:
j Business License
BUILDING
j
I
Residential Commercial
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Cost of P ject: f
Qty. if
ApVrt�able Fee ID
Fee Description
Fee Gmun
PPERNILTFEE
j Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING j
BPFIXTURE
Pbl-. Fixture
PLUMBING j
BPWSVCS
Main Water Service
PLUMBING j
BPSEWER
Sewers
PLUMBING
BPSEWAGE
j Sewage Disposal
PLUMBING
BUS IC
j Business License
BUILDING
j
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